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HomeMy WebLinkAboutSPEEDWAY #2439 - RETAIL FOOD SPEEDWAY#2439 317 Falmouth Rd. Cen. aqa �05 'l_ t c " Town of Barnstable BOARD OF HEALTH t John T.Norman Board OI Health Donald A.Gaudagnoli,M.D. BARN9'ABLE F.P.(Thomas)Lee,. pMAS& ., 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 487 Issue Date: 01/01/2022 DBA: SPEEDWAY #2439 OWNER: SPEEDWAY LLC Location of Establishment: 317 FALMOUTH ROAD HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IncloorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: G A FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: • , ��333 0 IPA 'e''�l• Town of Barnstable For : Initials: Date Paidi� � Amt Pd$�� . mumirAB Inspectional Services L� Public Health Division Check# Thomas McKean,Director b a` go 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: )rPPAXAJa11 2`1 J9 275 Co ADDRESS OF FOOD ESTABLISHMENT: 2) n �-a I m0A ". I4 yq n1` i S,6 2�)� MAILING ADDRESS(IF DIFFERENT FROM ABOVE) SO)('�� I 3OD �Jl C n e- 1� 1, �SS E-MAIL ADDRESS: P W0t TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO$ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / /_ TO NUMBER OF SEATS: INSIDE: OUTSIDE:(2 TOTAL: CD 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)?Al� 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 OWNER INFORMATION:FULL NAME OF APPLICANT C/fiCn 6wa LLC SOLE OWNER:ONO !� OWNER PHONE# �I�P) 0 3�—d. ADDRESS' 1'0. OV IS9 y ACCOSP- C1T Q l� I J y CORPORATE OWNER: S Dee U WCl V U-C CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: Nac� 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. N 1A 2. Z se oordinator twl )0 SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at littn://www.townofbarn-,table.us/healthdivision/aaplications.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 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc 60ImTown of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BAR,WAULL Paul J.Canniff,D.M.D. Hyannis, 200 Main Street, H 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: 487 Issue Date: 01/01/2021 DBA: SPEEDWAY #2439 OWNER: SPEEDWAY LLC Location of Establishment: 317 FALMOUTH ROAD HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: CQ� 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: J' t For Office Use Only: Initials: � ' �, Town of Barnstable d� Date Paid $ ■ARNSfABM : Inspectional Services Public Health Division 00 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP . RENEWAL NAME OF FOOD ESTABLISHMENT: .t u w 2-45q ADDRESS OF FOOD ESTABLISHMENT: 31'� fit ' ou-Nn U qY Qnn is MA 07-LO MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �. ��( 15�- l�� rel'1Se D I E-MAIL ADDRESS: C I�Si _ I n a 60 ,ec�SD� WA Drn SS TELEPHONE NUMBER OF FOOD ESTABLISHMENT: c,102) 7�- TOTAL NUMBER OF BATHROOMS: f, WELL WATER: YYEES NO ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: U OUTSIDE: —)IL 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? N IA IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? N{/` 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:Wpplication FonnsTOODAPP REV3-2019.doc OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: ONO OWNER PHONE# 0;i) 0 /3 92- ADDRESS .0 aX /5% L Cense- . SDr,n .tIaL. ng 455D W CORPORATE OWNER: f0eidN&VDATE J CORPORATE ADDRESS: • bDx 1 FD, ,S +N lot, 0{-E PERSON IN CHARGE OF DAILY OPERATIONS: ox it I qCL 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. NI A 2. / 13 20 SIGN OF APPLICANT DATE LICENSE COORDINATOR ***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 littp://www.towitofbarnstable.us/healthdivisioit/at)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.31 s`each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc 4 1h Town of Barnstable BOARD OF HEALTH John T.Norman Board Of Health Donald A.Guadagnoli,M.D. BASran F.P.(Thomas)Lee MAW, Daniel Luczkow,Alternate 200 Main Street, Hyannis, MA 02601 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: 487 Issue Date: 1/1/2021 DBA: SPEEDWAY #2439 OWNER: SPEEDWAY LLC. Location of Establishment: 317 FALMOUTH ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY 1 Town of BarnstableEnr Initials: i Inspectional Services . ,A •'3� Public Health Division � o _ Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Offices 508-862-4644 Fax; 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION(Non-Flavored) DATE -3Lb NEW BUSINESS OWNERSHIP RENEWAL. NAME OF TOBACCO ESTABLISHMENT: S tD e1C d hl ay ADDRESS OF TOBACCO ESTABLISHMENT: .3 AA pZ(D MAILING ADDRESS(IF DIFFERENT FROM ABOVE): C). ORD. 0 50 E-MAIL ADDRESS: .I_C-t1n5 i Y1� c d x I Q�.C Can TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 66-01 OWNER'S NAME:SDfMwA 2� 1 --aL4 OWNER'S PH#t _J3� OWNER'S AD.DRESS:�Ea kwp�Jl-1 QGI k al\ I S, W OZ.L b` CORPORATE NAME: _ O \ . T-CORPORATE ADDRESS: LI CORPORATE 1 DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE CODE/MA GENERAL:LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360,com/333996392 MA GENERAL LAW CHAPTER 270/SECTION 6: ba.4.-//malegislature.:gov/Laws/GencralLaws/PartIVITitl2UChalZter270/Scction6 ~ ***NEW BUSINESSES AND NEW OWNERS ONLY**' REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 509-375-6621 ALL APPLICANTS ARE REQUIRED TO S~MIT 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 LICENSE COORDINATOR SIGNATUR PRINTED NAME: -angelUu- O-Ty � DATE: I j 31 ZO Q:1Applicatidn Fornu1TOBACCO APP-NoiTavor 12-18-19.doex O?O Commonwealth of Massachusetts Letter ID:L1753337408 siq W' �� Department of Revenue Notice Date:September 11,2020 art Geoffrey E.Snyder,Commissioner Account ID:CGL-11945027-224 r41 o4'i mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES �I�'�I'I�III��II�I�III�I�I1�1�1"'IIII�'�I1��1�1���111����1111��1 SPEEDWAY LLC SPEEDWAYLLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at --———mass.gov/masstax-connect-to-view-and-re-print-a-copy-o€this license. --- --------------- -------- If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ st�c� sE�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes q ,kvt.ca� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CGL-11945027-224 SPEEDWAY 02439 Location ID: 11945027-0216 317 FALMOUTH RD License Number: 1456416768 HYANNIS MA 02601-2756 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2020 Expiration Date: September 30,2022 o o Commonwealth of Massachusetts Letter ID:L1483273792 ' smi — Department of RevenueNotice Date:September 22,2020 Geoffrey E.Snyder,Commissioner Account ID:CRL-11945027-227 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO �II�IIII��III'�II�'�I�"�II�'II�I�I'llll'�II'�III"1I'11I Jill IIII SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy_of this license._ If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE ----------------------------------------------------------------------------------------------------------------------------------------------- ' �`SF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco p4 This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ED: CRL-11945027-227 SPEEDWAY 02439 Location ID: 11945027-0328 317 FALMOUTH RD License Number: 1822464000 HYANNIS MA 02601-2756 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2020 Expiration Date:September 30,2022 � 0 Commonwealth of Massachusetts Letter ID:L0198465088 Department of Revenue Notice Date:September 11,2020 Geoffrey E.Snyder,Commissioner Account ID:EDL-11945027-239 04 mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS SPEEDWAY LLC SPEEDWAY LLC 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along the dotted line and display at your business location.At any time,-you-can-log-into your_ MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617)887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE ----------------------------------------------------------------------------------------------------------------------------------------------- asp t/top MASSACHUSETTS DEPARTMENT OF REVENUE M Retailer License for Sale of Electronic Nicotine Delivery Systems 9 ot This license must be posted and visible at all times.The sale of tobacco products to anyone under 21 years of age is prohibited. SPEEDWAY LLC Account ID:EDL-11945027-239 SPEEDWAY#2439 Location ID: 11945027-0454 317 FALMOUTH RD License Number: 1267243008 HYANNIS MA 02601-2756 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:September 11,2020 Expiration Date: September 30,2022 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. sAWMA®tF. = Paul J.Canniff,D.M.D. a Q 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: 487 Issue Date: 12/10/2019 DBA: SPEEDWAY #2439 OWNER: SPEEDWAY LLC Location of Establishment: 317 FALMOUTH ROAD HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: _ - _ Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: of rti For Office • Initials: Town of Barnstable Date Paid A Amt Pd$ J BARNsrABLE. . Inspectional Services f, V KAss. V t639' Public Health Division Intl QED MA't A Thomas McKean, Director - 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE IZ �� , 1 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 0 � X�X ` s t1V � E-MAIL ADDRESS: ( o y 1 TELEPHONE NUMBER OF FOOD STABLISHMENT: e I - a�5 TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO X ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/ /_ TO NUMBER OF SEATS: INSIDE: J — OUTSIDE: 0 TOTAL: 0 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?�I IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE ,RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL, MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT 14+ SOLE OWNER: YE /NO OWNER PHONE #(g31\ ADDRESS x bS� CORPORATE OWNER: 5;DP d.WaAj U_r, CORPORATE ADDRESS: �� 66 X 0 D , 6�p h n�,i e Id- OH q�:5d 1 PERSON IN CHARGE OF DAILY OPERATIONS: t o Ve' A— 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 2. W AUCENSE COORDINATOR 9/ Iql SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/api)lications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January Ist to Dec. 31`each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. Q:\Application FormsWOODAPP REV3-2019.doc 7 pf Town of Barnstable John T.NOF o BOARD No HEALTH � rman Board of Health Donald A.Guadagnoli,M.D. RAW Paul J.Canniff,D.M.D. MAS& F.P. Thomas Lee Alternate a � 200 Main Street, Hyannis, MA 02601 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: 487 Issue Date: 1/1/2020 DBA: SPEEDWAY #2439 OWNER: SPEEDWAY LLC Location of Establishment: 317 FALMOUTH ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY �F1ME For Office Use Only: Initials: Town of Barnstable $ , �� 1 � DateiPaid $ sARDISPABIA, Inspectional Services ,,, �. $ s639. k —11( Cm otaK Public Health Division _ AtFO�p Thomas McKean, Director C11� 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE, ($ 1 f 19 Ip NEW BUSINESS OWNERSHIP RENEWAL I— NAME OF TOBACCO ESTABLISHMENT: V� ADDRESS OF TOBACCO ESTABLISHMENT:�I�of M N A 16, rI vr�m,ft'iq . AAR o I'a 7'56 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: \ TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: OWNER'S NAME: i L 0 OWNER'S PH#o1 , - OWNER'S ADDRESS: CORPORATE ADDRESS: ,U ,; S I► I' CORPORATE �r� �►uc� N ySSo� ANNUAL: )< SEASONAL: DATES F O ERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) 0IDS 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/GencralLaws/PartI`I/Titlel/Chgpter270/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: ( LICENSE COORDINATOR 11 (, PRINTED NAME: ��l�� L�sl11G�1� �tC2P1 _, wC�v ou�'�wI1N LU r a- LA—C ' DATE: I� / I� / J� I Q:\Application Forms\TOBACCO APP-NonFavor I1-21-19.doc Dec 26 2019 07:24PM HP Fax page 1 �.eeduJ �y3 9 ESTABLISH NT'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 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: A Signn re frinied Name Date Punted Name Date Signature : —, � Printed Name Date - - l• rl..� Cr Sign ure ' Pteyl rinted Name Date I Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q.-Upplication FarmATOBACCO APR NonFavor 11.21-19,doc oho i� Commonwealth of Massachusetts Letter ID:L1903526528 s Department of Revenue Notice Date:September 4,2018 q j Christopher C.Harding,Commissioner Account ID:CGL-11945027-224 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstax'connect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ SacHosF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes FMr&�� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CGL-11945027-224 SPEEDWAY 02439 Location ID: 11945027-0216 317 FALMOUTH RD License Number: 1145247744 HYANNIS MA 02601-2756 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 tup� Commonwealth of Massachusetts Letter ID:L0486703744 � Department of Revenue Notice Date:September 4,2018 m �,�, Christopher C.Harding,Commissioner Account ID:CRL-I 1945027-227 p � mass.gov/dor RETAILER LICENSE FOR SALE OF.CIGARS AND SMOKING TOBACCO SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T is x Retailer License for Sale of Cigars and Smoking Tobacco rn �'�sxNt& This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CRL-11945027-227 SPEEDWAY 02439 Location ID: 11945027-0328 317 FALMOUTH RD License Number: 1349632 HYANNIS MA 02601-2756 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 VAW-0 DEPARTMENT OF'THE TREASURY INTERNAL REVENUE SERVICE WASHINGTON, OC 20224 10 LAR11C BUSINESS A140 INTERNATIONAL DIVISION , January 11, 2013 Charles VanBelle Team Manager Large Business & International Nicole Busey Internal Revenue Service Income Tax Audit & Legal Manager 433 N. Summit Street, Marathon Petroleum Corporation Toledo, Ohio 43604 419-213-5166 IRS Badge#1000220353 Dear Ms. Busey, Per our discussion I have researched the Federal Employer Identification Number (FEIN)for Speedway LLC. The FEIN for this entity is 31-1551430. Sincerely, Digitally signed by K67CB K67CB V Meo1mg emalldharleaT. Date'.1013.01.11 15:3623-0900' Charles VanBelle, Team Manager, LB&I Town of Barnstable BOARD OF HEALTH fl` Paul J Canniff,D.M.D. IJJJJ,, Board Or I Health 1,l Donald A.Gaudagnoli,M.D. BARNSTABLL John T.Norman �434. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate ram ► 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: 487 Issue Date: 12/20/18 DBA: SPEEDWAY #2439 OWNER: SPEEDWAY LLC Location of Establishment: 317 FALMOUTH ROAD HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: CQ FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: FIRE ro�ti For Office UsInitials: Town of Barnstable Amt Pd$�_ 9�AS& Inspectional Services ? i 1 ,0 � 7 AIF� 'A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fag: 508-790-6304 �2APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE II�3�1 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: 5 ADDRESS OF FOOD ESTABLISHMENT: 011 ib,(hrCA Ad. - Vo t)nl Es, MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 1) I)LV - 1 r.P, ,P l� f �r4Aeld E-MAIL ADDRESS: C / IZ TELEPHONE NUMBER OF FOOD ESTABLISHMENT: - TOTAL NUMBER OF BATHROOMS: 9 WELL WATER: YES NO � ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. 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 FonnsTOODAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT—rnDe?''d L p� SOLE OWNER: /NO OWNER PHONE# ��]" �1D f�j��,'j A 0/ ADDRESS CORPORATE OWNER: Lr FEDERAL ID CORPORATE ADDRESS: PO Nx ) 11 Dwt. 619n'roROH -7 5-T l PERSON IN CHARGE OF DAILY OPERATIONS: r Y e List(2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date �IA 2. /oZ/ /v /69 SIGNATU O APPLICANT DATE JOEY K ALLELE, TREASURER FOR SPEEDWAY LLC ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call-at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec. 3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\AppGcation FormsT00DAPPREV2018.doc 114E�,_ Town of Barnstable • Regulatory Services Department MUWSTABM MAS& Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO:TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION ; 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT L.L.. LA T NAME OIF APPLICANT FIRST NAME MIDDLE INITIAL C D /A 1-7 �61MONA Rd kInnIS, W�g STREET ADDRESS 5d?- 777 I - LU35 ) ) Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand the Sections VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided-on the next page). Each employee who sells tobacco products must sign the Employee Signature Form (provided herein). Si Lure Date JOEY K ALLEN, TREASURER FOR SPEEDWAY LLC Q:\Application Forms\TOBACCO APP2018 dob.docx • I y j Establishment TOBACCO SALES Employee Signature Form is or if use to indicate that the employee(s)of this establishment received and utderstood VII c. of the Barnstable Board of Health Prohibition of Smoking Regulatlari and the POP OJC i W 270 Section 6 of the Massachusetts General Laws which desm''bes the penalties � g art ol 9 i i g tobacco products to auy person under the age of eighteen(IS), Below are sections tl c. Barnstable Board.of Health Regulation: V AND DISTRIBLMON OF TOBACCO PRODUCT'S a ale T( I )rs—In conformance with the Massachusetts General Laws Chapter 270,Section 6, . o p rsM ra, corporation. establishxuon; or 'agency shall sell tobacco productg to,a minor. ath en D e working in an establishment licensed to sell tobacco product shall be required to ecei a4 0 of the Board of Health regsdatious and State Law regarding the sate of tobacco and J.' gn 'f dicating that such regutadonallaws have been received and understood, a copy of placed on file,in the Office of the employer and retained. Such signed forrrrs must e de ble for inspection,during the license holders normal business hours upon request of a nt Board of health. j retailers of tobacco products or,tobacco merchandise roust re that,. t, if a an to possibly be under 25 years of age,the customer present a valid State.fagged j iCe cation card or drivers ne'ewe with appropriate photograph to confirm that the ustc nae legal age to ttrchase the tobacco aduct I' �M a e(s)r'ec ived and understood Sections VUb. and VIIc. of the Barnstable Board of Tlu o olting guladon and Chapter 270 Section 6 of the Mamebusetts 0enerd LaWs: t�e Date. Printed Name Date ` l f 6, L4V tea&j Printed Name Date It ie Printed Name Date. Printed Name Date S i Printed Name' Date S Printed Name' Date Q: Ip i For sl 0 CO APP201$dob do= I f b tts� Commonwealth of Massachusetts Letter ID:L0486703744 MIR Department of Revenue Notice Date:September 4,2018 9 l Christopher C.Harding,Commissioner Account ID:CRL-11945027-227 mass.gov/dor RETAILER LICENSE FOR SALE OF.CIGARS AND SMOKING TOBACCO SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE --------------------------------------------------------------------------------------------------------------------------------------- PGHUSF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T 6A ;, Retailer License for Sale of Cigars and Smoking Tobacco FNrog This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CRL-11945027-227 SPEEDWAY 02439 Location ID: 11945027-0328 317 FALMOUTH RD License Number: 1349632 HYANNIS MA 02601-2756 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 CR szw MI�M Commonwealth of Massachusetts Letter ID:L1903526528 0Department of Revenue Notice Date:September 4,2018Christopher C.Harding,Commissioner Account ID:CGL-11945027-224 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is your Retailer License for Sale of Cigarettes(Form GT-3T). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE ----------------------------------------------------------------------------------------------------------------------------------------------- �cxusF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes m7 0v� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CGL-11945027-224 SPEEDWAY 02439 Location ID: 11945027-0216 317 FALMOUTH RD License Number: 1145247744 HYANNIS MA 02601-2756 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 �twe Town of Barnstable For Office Use Only: Initials: o� Date Paid Amt Pd$ Inspectional Services Check# Cash 4BARM�r9 s639. IN Public Health Division �� QED H1A�A 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT G� GZ EST BLISHMEN NAME (DB/A) Falwa& 8d. 'Wannls . PA OZOI - J -) ADDRESS OF BUSINESS PO 'MY 1500 - Licens MAILING ADDRESS (IF DIFFERENT FRONfABOVO a v LL OW ER'S NAME: LAST FIRST MIDDLE lfl=Qrdg!�pee rn q3`7-$Co -7��$� .. EMA PHONE# FEDERAL ID# 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). Signature �� _;rz�g� Date JOEY K ALLEN, TREASURER FOR SPEEDWAY LLC C:\Users\CZ54\AppData\Local\Microsoft\Windows\1NetCache\Content.Outlook\86NF5Q"CD\'TOBACCO APP2019 dob.docx r ESTABLiSt-t@9ENT'S NAME TOBACCO SALES Employee Signature Form i 'for'forin H f official use to indicate that the employee(s) of this establishment received.and J.xsto(dter 371: of the Town of Barnstable: Code and Chapter 270 Section 6 of the aeh se s neral Laws which describes the penalties for selling and/or glvint; tobacco 6ducts o n 'son under the age of twenty-one(21). below is Section 371.9.of the Town of ILI tab e, of ealth Regulation: l to M 371-9,Sale and Distribution of Tobacco Prat acts. + a�'c shall sell or provide a tobacco product, as defined herein,too person under The um legal sales age, The minimum legal sales age in the Town of Barnstable s Z�I rs of sage. I e t't ion: Fach person selling,or distributing tobacco products,as defined herein, i tall floc age of the purchaser by means of a valid government-issued photogrspbi- i e I1 ion contoining the bearer's date of birth that the purchaser is 21 years old or I'd t, rific ation is required for any person under the age of 27, .A foll wine ployee(s) received and understood Section 371-9 of the Town of Barnstable' ii d orb1c it Prohibition of Sinking Regulation And Chapter 270 Section 6 of the chiseit5 U ineral Laws: Printed Name Cate <to rc Printcd Name bate turn; Printed Name Mite lure Pr' ted Name Date turc Printed Name t]nlc .. � lure Printed Name Date titre Printed Name Date rs;(' ;� p sDl.m;ih�tRa ru�ufi�lt+ind�urs'.1Ne��uchr�Cua�cul.4h«tixrfi`tK(i!if'5Q I D)TOUCCO A111,2019 duly loco oF�Hergr TOWN OF BARNSTABLE , HEALTH INSPECTOR'S Establishment Name: V Date:! )6/a1A `Page: . of 1 OFFICE HOURS PUBLIC HEALTH DIVISION 6;00-9:30A.M. BARNSrABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DE ION OF VIOLATION/PLAN OF CORRECTION Date Verified � M63q. �0� HYANNIS,MA 02601 - ,. M -FRI. ' No Reference. R--Red Item:. PLEASE PRINT CLEARLY q n 508-8-862-4644 ' FOOD ESTABLISHMENT INSPECTION REPORT Name �` Dj& Tvoe of T Ins ection , Operation(s) cn Address l^"� . �,� Risk Food Service, Re-inspection e" Level d5eEP Previous Inspection y Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in harge(PIC) Time Bed&Breakfast HACCP 0 Q- , In: Other Inspector ( (Pb Out: P t�L A iA�rl �.y, Each violation checked drrequires^an�explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE 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 Asa 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. 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 violatiohs 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 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of violations observed,7 t anon-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 within 10 days of receipt violation,4 to 8 non critical violations=C. t of this order. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: 51ne igna e31.Dumpster screened from public view - Permit Posted? y N Grease Trap Previous Pumping Date Grease Rendered Y N#Seats Observed Frozen Dessert Machines: Outside Dining Y N ture Print: V _cre e Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N yl 0-Dumpster Sen? y N -,- .-. � � ,r-:.::Z--.r-r_ ,..r.. .•:P"'.,,-.-,.. _._�.�.w..^.e....,-.. �-.�.�-_.. 1•.. _" e. .•-.���,w-.• �---ti-r-�. ,�-t+.,,�-_ _ .a�•.�.. __ _ _ .rt,..,�-3-�...� •-•--�.-�. r,�-� .,,•a-�..._ .. .. .. w •�s i --X,^ ram' .1 c 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) JI)e_.onstrationof 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 - - - - 3-30214 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*- 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F * 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 * ( ) q 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR-- 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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* * 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* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs 3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec CONSUMER ADVISORY Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of � 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* g PP Y Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meals&Game Pathogens* e//°"°e 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 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 es should 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-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* 1 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 Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 1590.000 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. S11 Accessibility,Operation and Maintenance upplied with Soap and hand Drying Devices Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 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. 1 ,KE ro TOWN OF BARNSTABLE HEALTH OFFICE HOURSR'S Establishment Name: Date: Page: of PUBLIC HEALTH DIVISION e:00-9:30A.M. BARNS'1'ABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �p p39,a m HYANNIS,MA 02601 MON.-FRI. No Reference, R-Red Item - PLEASE PRINT CLEARLY sob-862-46" 'FDN1P' FOOD ESTABLISHMENT INSPECTION REPORT Name - )! Date? r� Tyne of f section J O�eration(s) Routi Address �, � l Risk Foo Service e-inspection Level RgK Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector --11" X`> 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) ❑ M � � Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ ICQ � i 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 �t ❑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 t ❑ 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 3 a aoaD Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: o ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusi ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today a items checked indicate violations of 105 CMR 590.000/Federal 00d 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 (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 if no critical violations observed,4 too 6 von-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 establishmeht operations. If C=2 critical violations and less than 9non-critical. If no critical water,sewage back-up,27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must g p,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) g lation 4 t ritical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: I ect r Si u rin. \� 31.Dumpster screened from public view L, r Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y NU #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signa/ r Print: Self Service Wait Service Provided Grease Trap Size Variance Letter.Posted Y N Dumpster Screen? Y N �O 6-J 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.* 2-103.11 Person-in-Charge Duties 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 590.004(F) EMPLOYEE HEALTH 3-302.1](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* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food.Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a 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 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective t;rn_oa 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 Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* 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 23-30) 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items non-critical * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate o then the re 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 3-501.14 A 3-202.18 Shellstock Identification ( ) Cooling Cooked and m 70°F to 41°F/45 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 and Fro45°F Tags/Records:Fish Products 5-203.11 Numbers,and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. p IKEr TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: c Date:�V/.( O Page:�_of.�_ `o w 3; OFFICE HOURS PUBLIC HEALTH DIVISION r.� 4 ,8:00-9t30 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. �A�6, .a�q•p,0 HYANNIS, MA 02601 MON.-FRI.I 508-862-464a No Reference R-Red Item PLEASE PRINT CLEARLY 'ED^"g` FOOD ESTABLISHMENT INSPECTION REPORT e Name Dat I ' voe of T f Ins ection Operation(s) qouti e ° Address 1 Risk F ervice Re-inspection _ Level etail Previous Inspection Telephone ;r Residential Kitchen Date: - Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness C C Caterer General Complaint Person in Charge(PIC) Time Bed 8 Breakfast HACCP In: Other Inspector i r Out: CA I ICo - Each violation checked requires an explanatio on a narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking - 590.009(E) ❑ `S 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 CHEMICALSOd 1 ❑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) 1 / - / ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures 4L e v ❑ 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) Corrective Action Required: No Yes Non-critical(N)violations must be corrected immediately or Overall Rating 4 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 i ms ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food C e. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its ag nt 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 Orion-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 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 )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC'-7 590.008 9 = 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8rion-critical violations C. 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 J v Y #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 Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 6 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.* i 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* 3-501.16A 7-102.11 Common Name-Working Containers* ( ) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) q 590.003(G) Reporting by Person in Charge* - - 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* -REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Foam* 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 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.411 Manual Wazewashing-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 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. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.I IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 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 gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001 4-602.1:1 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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. * 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 3-202.15 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 3-403.11E Commerc lly Processed Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated O g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 16 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 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3 402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Fonnback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 1 RCMR 590.000. pF IME row TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: 1 Page: of P o OFFICE HOURS PUBLIC HEALTH DIVISION BARNSTARLE. � 3:30-4:30P.M. 200 MAIN STREET Item Code C-Critical Item DESCRIPTION F VIOLATION/PLAN OF CORRECTION Date Verified � Ma3q. �0� HYANNIS,MA 02601 58-8 08-8MON -FRI.62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY iDrFD�p' FOOD ESTABLISHMENT INSPECTION REPORT Name DateQ Type of Jns c ion V Operation(s). Routin Address ^�� Risk Food Service e-inspection . Level et Previous Inspection Telephone esidential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness ^� Caterer General Complaint Person in Charge(PIC) Time Bed 8 Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation I Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HS 010.ProperAdequateHandwashing 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: ❑ 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 Suspension C N Official Order for Correction:Based on an inspection day,the items Embargo Emergency Closure Voluntary Disposal checked indicate violations of 105 CMR 590.000/Fe ral Food Code. ® g ❑ g y ❑ rY P ❑ 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 ( C-4)(590.005 B=One critical violation and less than 4non-critical violations 9 F ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i non-critical. . f critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8non-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8non criti I violations=C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: gector's a Print31.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 Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N 114 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 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) 7-102 2 590.003(C) Responsibility of the Person-in-Charge to .11 Common Name-Working Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140'F* Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Separation-Storage** 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 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* 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) Variance Requirements 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)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 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 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 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* TIMErrEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective//112001 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) F Ratites,Injected Meats-155' 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 3-401.11(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* 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-145'17 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 foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-A3.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors lasted above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140'F to 70'F 3-202.18 Shellstock Identification g hem Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F[0 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 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 1.009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °F� ► TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name:�� IAIA V Date Page: of ti 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 HYANNIS, MA 02601 _ MON.-FRI. No Reference R-Red Item. - PLEASE PRINT CLEARLY - 508-862-4W ,FOMO, FPPP ESTABLISHMENT INSPE TI N REPORT Name /' Dat of Inspection ^ s Routine AddressFAL' �= k ctio el Pre'iougip Telephone . ial Kitchen Date: Mobile Pre-opera o Owner HACCP Y/N Temporary Suspect I ess Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP Other in ­1 /�r 0' Inspector La Mt /r► Each violatio checked require an explanation on the narrative p g (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) ❑ O d 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 ❑ 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 o ❑ 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 [3 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. 25.Equipment and Utensils (FC 4)(590.005 B=One critical violation and less than 4 non-critical violations ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address receipt violations observed,7 to anon-critical iol 29.Special Requirements (590.009) days ati s. If 1 critical refrigeration. within 10 da s of i t of this order. violation,4 to 8non-critical violations C. 30.Other DATE OF RE-INSPECTION: I s or' Signatu e „ 00 int: 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 C's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y. N Dumpster Screen? Y N �c l/ i 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-Chazge Duties 3-302.14 Protection fro'rii riappioved Additives Contamination from Raw Ingredients 15 Poisonous or ioxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information—Original Containers* 590.004(F) * - * 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A)' Food Protection* 7-201.11 Separation-Storage*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 ChCharge* * 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 j 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a 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* I Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Cl Equipment* Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* sg°"°e tnrzoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 31l)CMR'2'2.0* 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* (A)-(D) Violations of Section 590.009(A)-(D)in cater- * Ratites-165°F I5 sec* in mobile food,temporary and residential ` Sources 10 Proper,Adequate Handwashing g' P � Game and Wild Mushrooms Approved B 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority y 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 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 24,01.11 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 Commercially -140°F* (Blue Items 23-30) 3-202.15 Package Integrity Tti C( ) C il)Y Processed RTE Food 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* F1g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A 3-202.18 Shellstock Identification ( ) Cooling Cooked PHFs from 140°F to 70°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours, 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 1.008 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* S:59OFormback6-2doc *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. r TOWN OF BARNSTABLE LOCATION e3/1) , SEWAGE # ;')s -�� j. VILLAG ASSESSOR'S MAP & LOT O INSTALLER'S NAME & PHONE NO. 01 v � / SEPTIC TANK CAPACITY / l J,"l !t9 �< � r ec LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WAT�ER BUILDER OR OWNER 710 d 1 . DATE PERMIT ISSUED: DD DATE COMPLIANCE ISSUED: t VARIANCE GRANTED: Yes No C ! Iv �� , 24 ZZ FROM David Thulin PE PLS FAX NO. 508 8887259 Jun. 21 2000 08:47AM P2 �0.yM0UtH R�RO + + u t3; DUPLEX 2HP GRINDCR PUMPS �+6�� �6 IN FI5FRGLASS PUMP CHAMBER 2 24" C.I. CO S S AT GRADE \ 1000 GALLON I-1-20 GREASE TRAP \ �9 t / \ Q \ \ / � 2" HDPE SEWER F.M. �5 0 30 60 30 \ ( IN •EET 30 ft. Siff sign / 17 FALMOUTH ROAD SHEET 3 OF 3 FROM David Thulin PE PLS FAX NO. : 508 8887259 • Jun. 21 2000 08:46AM P1 DAVID C. THUL/N, PE PLS / "— 211 MILL ROAD (508)88$-23a5 EAST SANDWICH.MASSACHUSETTS 02537 FAX(508)868-7259 06/21/00 Mr.Thomas A. McKean,R_S.,CHO Town of Barnstable Public Health Division 367 Maim Street Hyannis, MA 02601 ref. 317 Falmouth Road-Christy's Market,Dunkin Donuts Dear Tom: The following three sheet show details and as-built location of the grease trap at the ref. site. Very yours David C. Thulin,PE,PLS cc.Tom Powers L Gd.�rLG U ��c s e. h� C&ONWEALTH OF MASSACHUS*s v EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS V4 r DEPART-MENT OF ENVIRONMENTA v`�a 420 RIVERSIDE i '— VE, LAKEVILLE, MA 02347 508- 2 0 �aARGEO PAUL CELLUCCI RECEIVEO TPY BOB DURANDq Governor py� APR 2 1 _ Secretary JANE SWIFT To 2000 LAUREN A.LISS. Lieutenant Governor ' N1f0�F8�ARggE Commissioner April 19, 2000 Mr. Garry Blair RE: BARNSTABLE—BWSC/ASM Environmental Manager Quick Mart Store#30213 The Southland Corporation 317 Falmouth Road 814 Baker Road RTN 4-10415 Virginia Beach,Virginia 23462 NOTICE OF AUDIT FINDINGS/ VIOLATIONS/AUDIT COMPLETION Dear Mr. Blair: On March 1, 2000, you (in this Notice, "you" refers to The Southland Corporation) were notified that the Massachusetts Department of Environmental Protection, Bureau of Waste Site Cleanup ("the Department") had begun to audit cleanup actions conducted in response to a release of oil at the location referenced above. The audit was conducted pursuant to M.G.L. c.o 21E and the Massachusetts Contingency Plan (MCP) at 310 CMR 40.0000. This Notice is to inform you of the results of the Department's audit. DETERMINATION ' Although the Department has found violations in audited actions, no further actions are necessary to correct them. The Site Memorandum(Attachment.A) describes activities performed by,Department personnel during the audit, summarizes relevant site information, and lists the violations which were identified during the audit. The Department now considers the audit initiated'for this site on March 1, 2000,to be complete. The Department also acknowledges that a level of No Significant Risk has been achieved at the site. LIMITATIONS 0 The Department relied upon the accuracy of the information reviewed during the audit, including any information submitted during the course of the audit, to make these findings. These findings do not: (1) apply to actions or other aspects of the site that were not reviewed in the audit, (2) preclude future audits of past, current, or future actions at the site, (3) in any way This information is available in alternate format by calling our ADA Coordinator at(617)574-6872. DEP on the World Wide Web: http://www.state.ma.us/dep i,a Printed on Recycled Paper _2_ 0 constitute a release from any liability, obligation, action or penalty under M.G.L. c. 21 E, 310 CMR 40.0000, or any other law, regulation, or requirement, or (4) limit the Department's authority to take or arrange, or to require any Responsible Party or Potentially Responsible Party to perform, any response action authorized by M.G.L. c.21E which the Department deems necessary to protect health, safety, public welfare or the environment. 1J If you have`any questions regarding this Notice, please call Susan Pittenger at (508) 946- 2790. Please reference Release Tracking Number 4-10415 in any correspondence regarding this site. Very truly yours, Joseph F. Kowal, Chief Audit&Site Management Section K/SLP/rr Attachment: A. Site Memorandum CERTIFIED MAIL # Z 240 878 634 RETURN RECEIPT REQUESTED cc: Barnstable Town Council Barnstable Health Division Town Hall, 367 Main Street P.O. Box 34 Hyannis,MA 02601 Hyannis, MA 02601 ENSR 155 Otis Street Northborough,MA 02061 ATTN: Robert M. Cataldo,LSP DEP—BOSTON-BWSC DEP—SERO ATTN: Thomas Potter ATTN: Regional Enforcement Office Data Entry—RAO ti - Attachment A SITE MEMORANDUM RTN 4-10415 I. ACTIONS AUDITED The audit included a review of the following: • A Class A-2 Response Action Outcome Statement and supporting documentation, prepared by Robert L. Cataldo,LSP#9635. H. AUDIT ACTIVITIES The audit consisted of the following activities: • A Notice of Audit dated March 1, 2000. • A review of documents in the Department's file for this site,including but not limited to: "Phase II— Comprehensive Site Assessment and Response Action Outcome Statement," prepared by ENSR,dated April 1998,and received by the Department on April 28, 1998. "Release Abatement Measure Status/Completion Report,"prepared by ENSR, dated March 9, 1998,and received by the Department on March 10, 1998. "Release Abatement Measure Plan," prepared by ENSR, dated September 26, 1997, and received by the Department on September 29, 1997. '.L Groundwater Monitoring Reports, prepared by Fugro East, Inc. (Fugro), 1994 — 1997, received by the Department following each groundwater sampling event. "Phase I—Initial Site Investigation," prepared by Fugro, dated March 1995, and received by the Department on April 4, 1995. • A site inspection/meeting conducted by Susan L. Pittenger of the Department on March 22, 2000, to observe current site conditions and to discuss preliminary audit findings with Stephen Wright and Robert L. Cataldo (LSP-of-Record for the site)of ENSR. -2- III. SITE SUMMARY/SITE INSPECTION The disposal site is a portion of a 1.77-acre commercial property located at 317 Falmouth Road(Route 28), Hyannis (Barnstable), in an area of commercial development. The property has reportedly been in use as a gasoline service station since 1970, before which it was undeveloped. It is served by the municipal drinking water system, and has its own septic system. According to the October 27, 1999 Massachusetts GIS BWSC Priority Resources Map of the Hyannis Quadrangle, the site is not within a delineated Zone II or a Potentially Productive Aquifer. The nearest surface water body is an unnamed pond located approximately 100 feet southeast of the site. Laboratory analysis of site groundwater revealed a 120-day reporting condition in December 1993, when benzene and toluene were detected in groundwater from one of four onsite monitoring wells at levels greater than Reportable Concentrations. The Southland Corporation (Southland) filed a Release Notification Form on April 4, 1994. The Department issued"a Notice of Responsibility to Southland on May 19, 1994, requiring that a Response Action .Outcome or Tier Classification be filed by April 4, 1995. Beginning in March 1994, Fugro obtained groundwater samples from the site on a quarterly basis and submitted them for analysis for Volatile Organic Compounds(VOCs) by EPA Method 8020. Results were submitted to the Department after each sampling event. In 1996, the frequency of groundwater monitoring was reduced to triannually. At quarterly/triannual sampling events, depth to groundwater was generally measured between 12 and 15 feet below ground surface (bgs), and groundwater flow direction was determined to be to the southeast. Highest contaminant levels in site groundwater were generally detected in samples from monitoring well CEA-4, located approximately 30 feet downgradient of the gasoline underground storage tanks (USTs) at the site. Notal BTEX(benzene, toluene, ethylbenzene and xylenes) concentrations in groundwater from monitoring well CEA-4 ranged from levels below detection limits in December. 1996 to 19,090 µg/L (micrograms per liter, approximately equivalent to parts per billion [ppb]) in June_ 1994.E Concentrations of MTBE,(methyl tertiary 'butyl ether) in groundwater from CEA-4 ranged from levels below detection limits on several sampling dates to 860 ppb in January 1998.E Fugro submitted a Phase I — Initial Site Investigation- report 'and Tier Classification documents for the site to the Department on April 4, 1995. The site was designated a Tier II site. As part of the Phase I investigation, Fugro advanced five soil borings at the site in November 1994. Groundwater monitoring wells (FW-1 and —2) were installed in two of these to further delineate the downgradient extent of groundwater contamination. Fugro obtained soil samples from the groundwater interface from.each of the five borings. The samples were submitted for laboratory analysis for VOCs by EPA Method 8020 and Total Petroleum Hydrocarbons (TPH) by EPA Method 418.1. Laboratory results showed-contaminant levels in soil to be below Reportable Concentrations • A 1 ':4 r` f, Groundwater samples were obtained from existing and newly installed monitoring wells, as well as from the bottom of the three additional soil borings. All samples were analyzed for VOCs by EPA Method 8020. The samples obtained from newly. installed borings and monitoring wells were also analyzed for TPH by EPA Method 418.1. Laboratory.-results showed contaminant levels to be below applicable standards. ,,Groundwater-samples from borings FB-2 and FB-3 contained 30 mg/L (milligrams per liter, approximately equivalent to parts per million [ppm]) and 4.9 ppm of TPH, respectively. Boring FB-2 was located approximately 10 feet downgradient of the site's septic tank; FB-3 was located approximately 35 feet downgradient of monitoring well CEA-4. Fugro concluded that because there was no onsite source of fuel oil range hydrocarbons,the TPH in site groundwater was potentially due to contaminated drilling or laboratory equipment. Future testing was to include analysis of groundwater samples for TPH to confirm this conclusion. Quarterly sampling and analysis of site groundwater for VOCs was continued after the March 1995 Phase I report was- submitted. TPH analysis' was performed on groundwater samples obtained in August 1996. At that time, TPH was detected in groundwater from monitoring wells CEA-4 and FW-1, each at a concentration of 1.2 ppm. Qualitative identification by the laboratory indicated that the sample from monitoring well CEA-4 had characteristics similar to gasoline, and that the FW-1 sample had characteristics similar to lubricating oil. A lesser TPH concentration (0.8 ppm) detected in groundwater from the most downgradient well, FW-2, was found to resemble both gasoline and lubricating oil-range hydrocarbons. On March 14, 1997, the Department was notified that ENSR had acquired Fugro and would thenceforth be preparing all reports and submittals related to the site. ENSR submitted a Release Abatement Measure (RAM) Plan to the Department on September 29, 1997, to address contaminated soil encountered during the excavation of the three 12,000 gallon gasoline USTs at the site. The USTs, installed in 1976, were being replaced to comply with a Town by-law which mandated removal of USTs more than 20 years old. The RAM Plan allowed for the excavation, stockpiling, and off-site recycling of up to 200 cubic yards(c.y.) of gasoline-contaminated soil. A.RAM Status/Completion Report was received by the Department on March 10, 1998. In it, ENSR stated that "under the.RAM Plan submitted to the:DEP on September 26, 1997, the original volume of soil approved for removal was 350 cubic yards." This is inconsistent with the RAM Plan, which indicated that up to 200 c.y. would be removed. The RAM Status/Completion Report states that 475.06 tons (approximately_ 300 c.y.) of gasoline-impacted soil were .transported to the Bardon Trimount facility in Dennis, Massachusetts for recycling through asphalt batching. Bills of Lading were stated to have been submitted to the Department under separate cover; however, they were not found in the Department's file for this site. Copies were provided to the Department by ENSR on March 27, 2000. As described in the RAM Status/Completion Report, the UST excavation was 14 feet deep and 40 feet square. Groundwater was not encountered. Soils were screened for VOCs with a PID during excavation activities. Readings ranged from 0 ppm to 116 ppm, with the highest readings obtained from the southeast (downgradient) side of the excavation at approximately 10 feet below grade. Endpoint soil samples from the four walls and base of the UST excavation were submitted for laboratory analysis for Volatile Petroleum Hydrocarbons (VPH). Samples were also submitted for VPH analysis from excavations beneath the pump islands. jVPH were not detected in the pump island samples VPH levels detected in the'samples from the UST excavation are below MCP Method 1 Risk Characterization standards for Soil Category S-1. The RAM Plan had specified that endpoint soil samples were also to be analyzed for lead, and this was not done. However, the Department notes that a sample of the soil which was , stockpiled pending offsite.disposal was analyzed for metals, and its lead content was found to be 9.81 ppm. This is significantly lower than the Soil Category S-1 standard of 300 ppm. Therefore, the Department will not require additional soil samples to be obtained for lead analysis. ENSR submitted a Phase II - Comprehensive Site Assessment report to the Department on April 28, 1998. The report also serves as a Class A-2 Response Action Outcome (RAO) Statement. The MCP Risk Characterization Groundwater Category which applies to groundwater sampled from the six monitoring wells is GW-3. For the Phase II assessment, groundwater samples obtained in January 1998 were analyzed for VPH and soluble lead. Contaminants tested for were not detected at concentrations greater than Groundwater Category GW-3 standards. Background levels of contaminants detected at the site are assumed to be non-detectable in both soil and groundwater. ENSR stated that to achieve background conditions at the site would incur significant cost for no additional benefit in terms of risk reduction, and achieving background levels is therefore considered infeasible. ENSR concluded that the source of the release(the former UST system at the site) has been eliminated; a condition of No Significant Risk exists at the site and an Activity and Use Limitation is notnecessary to maintain it, and it is infeasible to reduce contaminant levels to background. Therefore, a Class A-2 RAO has been achieved at the site. A site inspection was conducted by Susan Pittenger of the Department on March 22, 2000. Stephen Wright and Robert Cataldo of ENSR were present at the inspection, along with an attorney representing the current site owner (Christy's of Cape Cod). Groundwater monitoring wells at the site have been decommissioned. Other site conditions were observed to be consistent with information in the Department's file. i 4 IV. SUMMARY OF VIOLATIONS Based on the information reviewed, the Department has identified the following violations in the actions audited. Although these violations were identified, no corrective action is required at this time. 1. There is no documentation in the Department's file to indicate that Public Involvement Activities were undertaken for the RAM conducted at the site in September 1997. This is a violation(Class II) of 310 CMR 40.0447(1) and 310 CMR 40.1403. Pursuant to 310 CMR 40.0447(1), Public Involvement Activities are required for RAMs. 310 CMR 40.1403 specifies that notification of the RAM be made, seven days in advance of its implementation,to the Chief Municipal Officer and Board of Health of the community in which the disposal site is located, and that copies of these written notices shall be sent concurrently to the Department. This Notice will serve as notification to these officials. 2. Bills of Lading for the soil removed from the site as part of the RAM were not found in the Department's file. This is a violation(Class III) of 310 CMR 40.0034(5). Pursuant to 310 CMR 40.0034(5), a completed Bill of Lading containing an original_ signature of a representative of the receiving facility shall be submitted to the Department within 30 days of the date of final shipment from the disposal site. Copies.of the Bills of Lading were provided to the Department by ENSR during the audit. 3. Discrepancies regarding the amount of soil to be removed from the site and the laboratory analyses to be performed on post-excavation soil samples were identified between the RAM Plan submitted on September 29, 1997, and the activities documented in the RAM Status/Completion Report received on March 10, 1998. This is a violation (Class II) of 310 CMR 40.0443(6), which states that any person implementing a RAM shall conform to all proposals and specifications contained in the RAM Plan. 4. A RAM Status Report was not submitted to the Department within 120 days of the Department's receipt of a RAM Plan for the site. This is a violation (Class II) of 310 CMR 40.0445(1). The RAM Status/Completion Report was received on March 10, 1998, 162 days after the RAM Plan was submitted. The violations identified above were either corrected during the audit, or the Department is not requiring additional actions to address them. Please be advised that the Department may use these violations to establish a pattern of noncompliance if pursuing future enforcement actions. FROM David Thulin PE PLS FAX NO. 508 8887259 Jun. 21 2000 07:36AM P2 r i SEE RISER AND - - - _ , - _ _ _ COVER DF,TAII, n I 24..E C0.VERS I A 1 in --8" KN0CK0UT (TYP) I 6„ PRECAST CONCRETE TANK PLAN PER 310CMR 15.226(2) 6" 3 I J Q C W 4 4 (fl o � 6.. I CJ v CAST IRON OR SCH40 PVC J { SUPPORTED 'BY HANGAR 6.. SECTION A-A 1000 GALLON GREASE TRAP NTS DAVID C. THULIN, PE, PLS (` GREAST TRAP & SEWER CONNECTION 2T 1 MILL ROAD EAST SANDWICH. MASSACHUSETTS 02537 CHRISTY'S MARKET - 317 FALMOUTH ROAD PREP. FOR: MIMOS DRAWN BY. OCT I cmK0 o. OCT HYANNIS, MASSACHUSETTS JOB Nc: 96-050 REV. SHEET t C= 3 SCALE: AS NOTED DATE. 6/21/00 f FROM :, David Ti,ulin Pr= PLS FAX NO. 508 8887259 Jun. 21 2000 07:37AM P3 —�- - -I -1 - - - - - •- -... _1 LOCATION OF SLCOND INLET TEE I I VVV WHERF. REOUIRED. TEE MUST BE F T -1 - - - - - - DIRECTLY UNDER OPENING 1 I I 1 I I I I A t ' I I � A 0. I '\ t I C.I. COVER 0 GRADE I t SEE "TYPICAL ACCESS COVER" I I INLET OR OUTLET TEE LOCATION - .J- - - - - - - - - - OUTLINE OF TANK BELOW NTS PLAN C.I. COVER 0 GRADE SEE "TYPICAL ACCESS COVER" BRICK ADJUSTING COURSE AND VARIES ..- _ CAS LING SET IN FULL MORTAR BED �^ 24" I.D. PRECAST CONC. RISER D WHERE "D" EXCFFDS 14" 24-0 OPNG �-- MORTAR, BED AND FILLET MORTAR JOINT" IN ALL AROUND STD. KNOCKOUT PRECAST CONC. TANK SANITARY TEE - SECTION A — A TAN A K RISER FRAME 8c COVER 1/2" = V- O„ : DAMD C. THULIN, PE, PLS GREAST TRAP & SEWER CONNECTION 211 MILL ROAD I� EAST SANDWICH, MASSACHUSETTS 02537 CHRISTY'S MARKET -- 317 FALMOUTH ROAD PREP. FOR: MmOS ORAWN BY: OCT I CHIM BY. OCT HYANNIS, MASSACHUSETTS im Na 90-ODO REV. 'REET I OF 3 SCALE: AS NOTED DAl'L. 6/21/00 FROM David ThGlin PE PLS FAX NO. 508 8887259 Jun. 21 2000 07:37AM P4 w � • } DUPLEX 2HP GRINDER PUMPS tea'' IN FI8ERGI.,.ASS PUMP CHAMBER 4pIJ�� pG 2 24" C.I. CO S AT GRADE U. \ 1000 GALLON H-20 GREASE �q��0 TRAP \ SFS \ �9 / \ ` 1-1QPE SEWER F.M. 13 0 120 30 60 30 \ ( IN EET } site 1 'nch 33() fi, sign / 17 FALMOUTH ROAD SHEET 3 OF 3 0 No.G1 /J{ � �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppricati.on for 30igoOl 6pftem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )bandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. �j7 t�,o�. )Woe�i� c Ir o21 suers -OP e . C, /-4 C" Assessor's Map/Parcel tj �� — O 5, 7 Q S' �1�����r-t �T 1 .dN,�1 �aG� I�talller's Name,Address,and Tel.N,�o.. 4 S Designer's Name,Address and Tel.�Io. oug Co 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 gallons per day. Calculated daily flow���� �•� .U3 gallons. Plan Date e--d® O Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ' n Answer when applicable) O`tJ ����' Nature of Repairs or Alterations( pp ) �i� �� 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 Certifi- cate of Compliance has been issu d by this B d of Heal Signed Date l r 9` ad Application Approved by ! Date Application Disapproved for the following reasons Permit No. I�F 00 ^ IF 2C Date Issued ---------------------------------------- / THE COMMONWEALTH OF MASSACHUSETTS Bntered in computer: Yes PUALIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS Z, [ppficatibn for Mopo.5al *pmem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(1/)Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. G. Owner's Name,Address and Tel.No. 3 7l 1%•O rirG�'11 �IV 121 s c �. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i IA) 3;00 A,,O / r Type of Building: / Dwelling No.of Bedrooms Lot Size / /sq.ft. Ay'Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures '/ Design Flow _ gallons per day. Calculated daily flowv�,04 ew6lj3�dw gallons. Plan_ Date e 0244 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) or�e5 4!! o t!f' AP/ it. 4 c 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 Certifi- cate of Compliance has been issued by this B d of Heal r Signed r Dater —,2a. ad Application Approved by DateO' �" <' Application Disapproved for the following reasons Permit No. 1W00C, ,e... ! Date Issued ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,ahat the On-site Sewage DDiisp�osal System Constructed( A<Repaired( )Upgraded( ) Abandoned( )by Ze at has been constructed in accordance with the provis'ons of Title 5 and the for Disposal System ConstrucWn Permit No�V AA -!� `bated Installer _ —'° Designer d,r� p r 0 The issuance of this pem sh 1 not b construed as a guarantee that the to will fu/nctt'on deb' ed.� Date Inspector --------------------------------------- No. 0,0® / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mis�paar *potem Construction Permit Permission is hereby granted to Construct( .,)Repair( )Upgrade )Pq,,,don )L,.,� System located at = (� .VVe � F and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this peAiit. Date: Approved FROM David T KU 1 i n PE PLS FAX NO. 508 8887259 �Jun. 21 2000 07:35AM P 1 f DAVID C. TMULIN, PE PLS 211 MILL ROAD (508)888-2345 EAST SANDWICH.MASSACHUSETTS 02537 FAX(508)888-7259 I 06/21/00 Mr. Thomas A. McKean,R.S., CHO Town of BarrlStable Public Health Division 367 Main Street Hyannis, MA 02601 ref. 317 Falmouth Road-Christy's Market,Dunkin Donuts Dear Tom: The following three sheet show details and as-built location of the grease trap at the ref. site. Very yours David C. Thulm,PE, PLS cc. Tom Powers 1 y c r-rGe Kim® Consulting•Engineering•Remediation 155 Otis Street Northborough,MA 01532-2414 (508)393-8558 FAX(508)393-8647 April22, 1998 http://www.ensr.com Thomas McKean File#: 6230-141 Town of Barnstable Health Division 367 Main Street Hyannis, Massachusetts 02601 Re: Quik Mart Facility#3021°3 3.17 Falmouth Road Hyannis, Massachusetts RTN 4-16415 Dear Mr. McKean'. Pursuant to 310 CMR 40.1403 (3) (e) and (f) of the Massachusetts Contingency Plan (MCP), this letter is to inform you that a Phase 11 Comprehensive Site Assessment Report and a Response Action Outcome Statement have been submitted to the Massachusetts Department of Environment-al Protection(DEP) on behalf of The Southland Corporation for the above-referenced site. This document is available for review and copying at the DEP - Southeast Regional Office located at 20 Riverside Drive, Lakeville, Massachusetts. If you have any questions, please contact the undersigned. Sincerely, ENSR Christopher G. Mariano Project Manager cc Garry Blair—The Southland Corporation DEP.Southeast Regional Office ..+.�.. ,�♦ e.. ., s a .. d.,�� .. ._ «s tc li .4 +rya _ '� _i. .. ., a .. 0 Rec cetl PapeUScp-based_nks f T� �Gamir��rerava,�a ^�G�czatciclivae�i - �e��./xCmenG` �rrxe C��i r�ccea l0 ecuefe a�' J-cc�cc CJa�eCii� - ;,4 arra��u�aaince GGncl Notification for Removal or Closure of In Place Storage Tanks Regulated Under 5 ` .00 Forward completed form,signed by local fire department,to: Mass. UST Compliance Unit, - - • Dept of Fire Services, One Ashburton Place-Room 1310,Boston,MA�02�108-1618 Include copies of FP-292, Fire Department Permit and both sides of Re istere-Tank Date Rei /-21-98 P P g n'y �/ Disposal Yard Receipt (FP-291). 9�, ��A Fire Dept. ID# O/92Z (Fire Department retains one copy of FP-290R) �.= Z ����� ¢°Fire Dept. Sig. This form is to be used for notification.for removal of Underground Storage T��as�p/ - Only Piping. �+ If a storage facility has UST's which are to remain in use, an entire amended FP-2900 ? 'lac lityCer (long form) must be filed. B. Date Entered i C. Clerk's Initials Note: "Facility street address"must include both a street number and a street name. j Post office box numbers are not acceptable, and will cause a registration to be D. Comments returned. If geographic location of facility is not provided, please indicate distance and direction from closest intersection, e.g., (facility at 199 North Street is located) 400 yards scutheast of Commons Roar; (:ntersection). i I. OWNERSHIP OF TANK(S) II. LOCATION OF TANK(S) Owner Name(Corporation,Individual, Public Agenc•,or Other Entity) If known,give the geographic location of tanks by degrees,minutes,and �f seconds.Example:Lat.42,36, 12 N Long.85,24, 17W q� r2 lib iz 7o.d. r� Latitude 1l?V 3N 40 r1W Longitude 701° /8 /d///A/ f'• ©• 7// d tj I ,f2T ;1P 301/3 Street Address OffInce and cirectlon tram closest intersection(see note aoovel 317 4/j L.tia r.0 X Faulity Name or Company Site identifier,as applicable 4 '/mac -zf'Z z/-0 eft i ty rate Zip Code Street Address(P.O.Box not acceptable•see note acove) ff 4 LLifI 1a�aaW.,S /`//� O tloo/ ounry Cit� State ZIP Code fL�- 07// 7s— /06s,/3/ �41z_, ' ?�l��E Phone Numoer(Inciude Area Code) Owners Empioyer Federal 100 County III. TANKS/PIPING REMOVED OR FILLED IN PLACE Tank Number Tan / Tan T00040ZQ Tank No. Tank No. 1. Tank/Piping removed or filled in place ]� (mark all that apply) A. Substance last stored L k B.Tank capacity gallons an / — C. Estimated date last.used (mo./day/yr.)— 'q 2 z/S7 D. Estimated date of removal (mo./day/yr.) I 2t �7 09/ 97 09 ZL S� -------------------- ---------- ---------- E. Tank was removed from ground �X F. Tank was not removed from ground 0 0 Tank was filled with inert material Describe material used: ---------------------------- ---- ------------ G.Piping was removed from ground H. Piping was not removed from ground 0 0 �— I. Other, please specify 2c \ =P•290R(revised 11 96) OV_. 1 Tan� k Number (cont.) Tank No.OZ/ I Tank No. 0'dL Ta�Jo. Oa3 Tank No. I Tank No. 2. Tank closed in accordance with 527 CMR 9.00 R Yes = No ;-Yes _ No -7Yes = No ` Yes = No = Yes = No A. Evidence of leak detected :: Yes $No Yes LS No Yes :X No = Yes = No = Yes = No E3. Mass. DEP notified 7 Yes No Yes = No Yes = NoC Yes = No = Yes ^ No 1. Mass. DEP tracking number 2. Agency or company performing contamination assessment I declare under penalty of perjury that I have Personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the informa- tion, I believe that the submitted information is true, accurate, and complete. Name and official title of owner or owners Signature: Date: authorized representative (Print) Glarry n3 ?-290R(revised ' ,,96) Town of Barnstable Inspectional Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO November 12, 2021 Speedway LLC ATTN: Mark Yeiga P.O. Box 1580 Springfield, OH 45501 RE: Speedway #2439 317 Falmouth Road Hyannis,MA 02601 On multiple dates this past year, The Town of Barnstable Department of Public Works notified the Public Health Division that raw sewage was overflowing onto the ground at the drive-thru area of Dunkin Donuts, located at 317 Falmouth Road, Hyannis, MA. Each time the Health Division was notified, a Health Inspector immediately went on site and observed raw sewage on top of the ground. Management and personnel inside the building were not aware of the issue each time, and allowed the public to continue to drive through the raw sewage and walk through the raw sewage. The businesses were then immediately ordered to cease and desist operations until the issue was resolved, the sewage was pumped, and affected paved area was cleaned and sanitized properly. Due to these multiple overflows, deemed hazardous to public health, it is strongly recommended that you hire a sewer maintenance company to conduct weekly checks on your :system and to take any needed actions to prevent any additional overflows of raw sewage onto the top of the ground. A copy of this letter is being sent to the Chairman of the Board of Health and to the Superintendent of the Department of Public Works. If you have any questions, please contact Thomas McKean at 508-862-4640. PER ORDER OF HE BOARD OF HEALTH omas McKean, R.S., CI Agent of the Board of Health CC: John Norman, Chairman of the Board of Health Dan Santos, Superintendent of Department of Public Works Q:\Order letters\Sewage Violations\Speedway 317 Falmouth Road Hyannis Letter 11-12-2021.docx - a 7­7 IWO- 4- 7, k kL, �7 ''77" :7- 7 #L v,, Ns j, jk% j z 00 00 CATCH BA81N SA rJE -TRAFFIC SIGN Z7 0 44�22 '41 71 y 43.78 OVERHEAD TRAFFIC SIGNALS, POLE 44.77 IS( u CATCH BASIN b'11k DPAIN MH t 4.86 Fit SUNB BS.MON.WE L LOT 287 - N/P JOSEPH P. FERRARO V) L�C_17786G CEPT, 129697 X 4 U-1 5.24 G NS wv 4.94 S.MON.WE QBS,MON.WELL WATER GATE 4 W_#8 45.0 )K 4A 47 A, FU rn 7 ,11 � 'I, LL , _pGIROIJI AND 10 jy\S 00 NQTES- U "-'\1"'S NUMBER, 292-5 0 1 ASSES,�` 2. ZONINt- STRICT: URBAN BUSINES5 p4lD -77 , G �W_#7 5. ELEVATIONS . SHOWN T ON COMPILEU FROM AN 4 T;,,r; OPOG, _)PHIC INFORMATI ON HE ROUND INSTRUMENT SURVEY _ARE BASED ON THE NATIONAL 45.68 ' GEODETIC ERTICAL DATUM. L LOT� -5 O8S.MON.WEL 6, 1� wv t7 REFERENCE: L,C,1831537A" 1 . 78 ACRES 7. , BENCHMARK: WrDPANT 202 ELEV 47�83 TELEPHONE E300TH Aro VENDING 4 0f,pAVFMENT 2 x MACHINES FENCE' �Sl P", LOT, 137 N/F COMVONWEALTH - OF7 MASSACHUSETTS t-,j BOOK 456 PAGE ,18 3'6.C Unless and until such tirne as the original (red) stomp of the -W—#5 responsible Professional Engineer, or Professional Land Surveyor appears on this plan: (A) no person or persons, including any municipal or other �3 the Infcri-notion contained herein, and W—04 public officials, may rely upon (8) this plan remains the property of Holmes McGrath. Inc. TP 0 #3 34 #1 #2 LOT 141 ............ AL INVESTMENT TP N/F PESIDENTI ST L.0 17786E CERT. 132535 DATE DESCRIPTION jDraw ' �heqked n 'f6 40 - 0 N S , R S I EN I 48 - 48, PLOT PLAN PREPARED FOR -95.29 7—ELEVEN , STORE # 30213 LOT 5, BEARSE'S' WAY IN , HYANNIS M A,, BARNSTABLE , � ' LCIT 6 A" OF DATE: MAR SCALE: 1 20' 28, �1 996 1AM P SWFT N/F WILL -mcgr holmes :-and , oth nc ' BOOK, 1341 ,PACE :790 chn'i englneers,,,and fond surveyor�s 200 main �street faill"hwt 2540 ED DRAWN: :� PAB_:� CHECK §60'46PP'.bVVG 96046 -M JOB 'NO DWG �'NO.:-62-3 20 ��L