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CAPE COD PACKAGE STORE - RETAIL FOOD
CAPE cob PACKAGE STORE_1495 Fal Rd _ Cent mouth . flS1rvi11e r II c* � pErt Town of Barnstable BOARD OF HEALTH John T. Norman Board of Health Donald A.Gaudagnoli,M.D. B;+,rc,NSTAoa,e, = F.P.(Thomas)Lee,. Ms1S4 Daniel Luczkow,M.D. Alt. +639• .� 200 Main Street, Hyannis, MA 02601 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: 153 Issue Date: 01/01/2022 DBA: CAPE COD PACKAGE STORE OWNER: CAPE COD PACKAGE STORE INC Location of Establishment: 1495 FALMOUTH ROAD CENTERVILLE„ MA 02632 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Offic Initials: Town of Barnstable Date Paid Am>t_.Pd$ snxrrsrnsi� Inspectional Services f 9� i63y 1 �E `� Public Health Division Check# Thomas McKean,Director C 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE AFOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL / NAME OF FOOD ESTABLISHMENT: ax-6d—' &Ccfcl� A G �/ / ADDRESS OF FOOD ESTABLISHMENT: `Y��/C�ciLfOit�i�� , ���lL��/�,i�QWZ ' 1 ` / MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 1l/y� E-MAIL ADDRESS: 6'zpi TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (5-V ) 77 r- ZD&S TOTAL NUMBER OF BATHROOMS: 2 WELL WATER:YES NO ✓ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V 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) *** 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 REV3-2019.doc 1 OWNER INFORMATION: / FULL NAME OF APPLICANT �rC��t� SOLE OWNER: YES/ / OWNER PHONE # �V d ?J —go&5 ADDRESS_ 1 y75 /i��s � �� j�,ME OrZ&yL CORPORATE OWNER: CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date r 1. / 2. AV14Q��� to 2� �S1GNAT 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 http://www.townofbarnstable.us/healthdivision/ai)plications.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.31'each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Q:\Application FormsTOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. +`BARN MULL Paul J.Canniff,D.M.D. M' F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 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, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 153 Issue Date: 01/01/2021 DBA: CAPE COD PACKAGE STORE OWNER: ANDREA PENDERGAST Location of Establishment: 1495 FALMOUTH ROAD CENTERVILLE„ MA 02632 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2 O21 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q.h FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office User;/_2S Town of Barnstable Initials:Date Paid � Amt Pd$ � BAMMBLE.D! Inspectional ServicesXtAffi. '�b ��� A,Eo ,�a Public Health Division v 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 � 2'DATE L1 ' NEW OWNERSHIP RENEWAL ✓ NAME OF FOOD ESTABLISHMENT: 660 U i ADDRESS OF FOOD ESTABLISHMENT: 1 �� 5fAdW1_/64 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: OA&-eA& a>° Cell TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (U�IsB ) 7?� - Z06� Vk TOTAL NUMBER OF BATHROOMS: a WELL WATER: YES NO >/ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENS 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) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:1Application FormsTOODAPP 2020.doc l , OWNER INFORMATION: FULL NAME OF APPLICANT / t. 10eA — SOLE OWNER: a/NO OWNER P ONE# (G�U�� 776 —632-7 ADDRESS CORPORATE OWNER: CORPORATE ADDRESS: `� �'� f CC���� l`r.� C QJ7/fl�, AW b-Z63�—, PERSON IN CHARGE OF DAILY OPERATIONS: .gA 4f�— 074PkIl t 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. ZA Z02o SIGNATUIVOF 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 httt)://www.townofbarnstable.us/healthdivision/a1)plications.asil. 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 1 st. Q:\Application FoansTOODAPP REV3-2019.doc 1 Bellaire, Dianna From: Andrea Pendergast <andrea@capecodpackagestore.com> Sent: Monday, December 07,2020 10:43 AM To: Bellaire, Dianna;office@capecodpackagestore.com Cc: 'Donald Underhill' Subject: RE:2021 Tobacco/Food Permit- Cape Cod Package Store Hi Dianna We do not sell e-cigarettes or any kind of vaping devices Let us know if you have any further questions. ` Thanks Stay Healthy and Be Well, Andrea L. Pendergast Co-Owner Cape Cod Package Store Fine Wine&Spirits p1S'�pa{p� `y. NJ CAP1 CmU I GACKAGE$TOM Office:508-775-8608 Store:508-775-2065 Shop online at www.capecodpackagestore.com Download our CCPS app on your Phone Like us on Facebook;Follow us on Twitter,Pinterest&Instagram Cape Cod Package Store Fine Wine&Spirits would love your feedback. Post a review to our profile. https://g.page/capecodpackagestore/review?gm . Help make the earth a greener place. If Possible resist printing this email and'oin us in saving Paper. From: Bellaire, Dianna zDianna.Bellaire @town.barnstable.ma.us> Sent: Monday, December 7, 2020 9:53 AM To:andrea@capecodpackaeestore.com;office@capecodpackagestore.com Cc: Bellaire, Dianna<Dianna.Bel laire@town.barnstable.ma.us> Subject: 2021 Tobacco/Food Permit-Cape Cod Package Store j Importance: High Hi, This is confirmation that I have received your renewal applications. However,they will remain in pending because this year there is anew MA License for tobacco. If you sell e-cigarettes,e-juices,vaping juices or electronic delivery systems, you will need to provide a copy of your MA License Electronic Delivery Systems OR Please reply to the email with a confirmation-you DON'T sell and I will make a note on the account.Once I have one of those items, I can release the permit. There is no inspection requirement this year due to COVID restrictions. 1 ' 4 IKE Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. ©ARNSTAUM .: F.P.(Thomas)Lee A bye .,� 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 153 Issue Date: 1/1/2021 DBA: CAPE COD PACKAGE STORE OWNER: CAPE COD PACKAGE STORE INC. Location of Establishment: 1495 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, IRS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY • For Office Use Only: Initials: Town of Barnstable Date Paid AmtPd$ BARNwABm , Inspectional Services �T�T���Il j A.MASS. 9. �`� Check# �1. W Public Health Division _ too aoti a2a Thomas McKean, Director i 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT.. PERMITAPPLICATION-(Non-F..lavored). DATE. 2� �. NEW BUSINESS OWNERSHIP RENEWAL L NAME OF TOBACCO ESTABLISHMENT: ADDRESS OF TOBACCO ESTABLISHMENT: G 5 t u- A., Vic._' _ (/ 6 ' Z MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: P TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (_S 775 - '266 S— OWNER'S NAME: 1$14/'96- L �& k OWNER'S PH#(rl) 716- G 327 OWNER'S ADDRESS: c L� G---,jV&tS %m / CORPORATE NAME —�(XA, G. CORPORATE ADDRESS: -( l S 1"��M 014JI- ;c(t . [kA ORATE FID# ANNUAL: V SEASONAL: DATES OF OPERATION:_/ / TO 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/33996392 { MA GENERAL LAW CHAPTER 270/SECTION 6: i hgps:Hmale�islature Gov/I,aws/GeneralLaws/PartIV/Titlel/Chp,ter270/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 s 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 E 1 SIGNATURE: ; PRINTED NAME: �°� �—���-. �— DATE:. C/R Q:1Application Formsl"TOBACCO APP-NonFavor 12-18-19.docx �I r t ESTABLISHMENT'S 6AME 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 y 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 u 371-9.of the Town of Barnstable Board of Health Regulation: Sales to Minors—§371-9. Sale and Distribution of Tobacco Products. k 1. No person shall sell or provide a tobacco product,as defined herein,to a person under k The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. i. i 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of x Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: F pp C S �e16� Sign ek nd Name Date ture Printed Name Date (PAr 1 e Printed Name Date ign Printed Name Date n i a r `Printed Name Dat r gnature Printed Name Date u �_� Si=nature Printed Name Date Q:\Application ForrnATOBACCO APP-NonFavor 12-18-19.docx ' l ESTABLIFYHMENT NAME i TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270. Section 6 of the.Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any-person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: -: z Sales to Minors—4 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each-person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic ' identification containing the bearer's date of birth that the purchaser is 21 years old or g older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: > � I Ll Signature, Printed Name Date ..... ........ { Signature. Printed Name Date Signature tktame Date .� jV 1clr. ��-1,�ssv,✓ I �� �� Signature Printed Name Date 2 J /� „f S' ture Printed Name v Date ��er �ia��i�0 1[ 12312-0 Si ature Printed N me Date a S. i gnature Punted Name Date I Y i Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.doex . . r Cb6k 6�_4 c ry STABLISHMENT'S fighE 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 3 71-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—4.371-9. Sale and Distribution of Tobacco Products. 1` 1, No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. i z 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: eK Si e� Printed Name Date 1 ature 'Printed Date Signatur ranted Name Date Sign Printed Name Date Signature Printed Name Date Signature Printed Name Date s: Signature Printed Name Date f Q\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx y k '4 Commonwealth of Massachusetts Letter ID:L1140112960 0 Department of Revenue Notice Date:October 16,2020 Geoffrey E.Snyder,Commissioner Account ID:CRL-10761789-009 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO n Illul IIII I Intl I Illun illnl nul o— o CAPE COD PACKAGE STORE INC CAPE COD PACKAGE STORE INC N e 1495 FALMOUTH RD CENTERVILLE MA 02632-2945 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 •----------------------------------------------------------------------------------------------------------------------------------------------- Hos� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking g Tobacco ' tro4 This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. CAPE COD PACKAGE STORE INC Account ID: CRL-10761789-009 1495 FALMOUTH RD License Number: 1420544000 CENTERVILLE MA 02632-2945 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 16,2020 Expiration Date:September 30,2022 5 Commonwealth of Massachusetts Letter ID:L1579376192 It +: Department of Revenue Notice Date:October 20,2020 Geoffrey E.Snyder,Commissioner Account ID:CGL-10761789-006 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES III'I'II1��I11i1�111'I�11�'lllllld�l��'��II'I'II�� 11'll�lll� CAPE COD PACKAGE STORE INC o CAPE COD PACKAGE STORE INC 4;= 1495 FALMOUTH RD CENTERVILLE MA 02632-2945 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/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 . ------------------------------------------------------------------------------------------------------------------------------------------------ c+�u� ., MASSACHUSETTS DEPARTMENT OF REVENUE Form.CT-3 Retailer License for Sale of Cigarettes This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. CAPE COD PACKAGE STORE INC Account ID: CGL-10761789-006 1495 FALMOUTH RD License Number: 1931855872 CENTERVILLE MA 02632-2945 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 20,2020 Expiration Date: September 30,2022 0 � Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. �,►nxsren� Paul J.Canniff,D.M.D. 16 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056,146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 153 Issue Date: 12/10/2019 DBA: CAPE COD PACKAGE STORE, INC. OWNER: ANDREA PENDERGAST Location of Establishment: 1495 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2OZO RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �"E t For Office Use Only: Initials: r,p� ti Town of Barnstable BAMSTABLE. : Inspectional Services J MASS, '639 ,� Public Health Division check# a �fD MAC A Thomas McKean, Director 10 vi( I�P5 ` 200 Main Street,Hyannis,MA 02601 t Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE �� NEW OWNERSHIP RENEWAL N NAME OF FOOD ESTABLISHMENT: !'/)pe Coal /Zt(;,(QA,-,Pbm jhc, ADDRESS OF FOOD ESTABLISHMENT: 1112Y Falmoah Rock 0ef7k le,).Pr ®D&�fi MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: adhit�c�L-e�a4t Whr& cofn TELEPHONE NUMBER OF FOOD ESTABLISHMENT: J06.5 TOTAL NUMBER OF BATHROOMS: d WELL WATER: YES_NO Y/... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V 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_ REO UIREMENTS. 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 �LRETAIL 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 �1 OWNER INFORMATION: FULL NAME OF APPLICANT ,/ kea. k. PEide129as� SOLE OWNER: YES( 'O ?� OWNER PHONE# (S-[�-P)77J Y&o,? ADDRESS �� CORPORATE OWNER: i ,LAD PG4 �t6 (�Z , �VIP� CORPORATE ADDRESS: (��(R5r2(.M y7 A &d 0enfi l% , ;tA a& PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment.. Certified Food Managers Expiration Date Allergen Awareness Expiration Date L 4— 2. / / 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/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec. 31"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 ' For Office Use Only: Initials: pFINEfp Town of Barnstable ff ��' Date Paid 1 j4 Amt Pd$ d BARNSTABIZ Inspectional Services 1-53 iOPFpa�O Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE NOY a0f9 NEW BUSINESS OWNERSHIP RENEWAL J NAME OF TOBACCO ESTABLISHMENT: (�7GL�- LaGtL a wfee ADDRESS OF TOBACCO ESTABLISHMENT: J�l9S F( t nwyOi Road- ('cerLkz�'Jle . ?tov 02G 3� MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: "2eQl COT TELEPHONE NUMBER Or F TOBACCO ESTABLISHMENT: Ua )7`1S - 206s OWNER'S NAME: Adim. L P0)der2au.sf OWNER'S PH# OWNER'S ADDRESS: CORPORATE ADDRESS: 1yq raZ MOIM 90e Cenlev�/lP�hrg CORPORATE FID# //0,2/ ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO 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/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https://malegislature.gov/Laws/GeneralLaws/PartIV/TitleI/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATU E: ,p PRINTED NAME: !P(� f �ue�rkrf DATE: I IRS' l 1 Q:Vlpplication FonnATOBACCO APP-NonFavor 11-21-19.doc e � ESTABLISIbANTIS NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—&371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: LSignature Printed Name Date Signature Printed Name Date a 61-jg S' a Printed Name Date Signatu Printed Name Date i Printed Name Date Panted ame Date tgnature I Pritea Name Date Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc y . t a l A ESTABLISHM%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 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature Printed Name Date Si natu a Printed Name Date ? t-S�,Je v1__ -3 Signature Printed Name Date ature r- Printed Name Date ofi-eIVII-OeMAW 0 12— q °J Signat#e Printed Name Date NS Lnnted Name Date Co Signature Printed Name Date Q:\Application FonnATOBACCO APP-NonFavor 11-21-19.doc r Jnc. 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 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Gi-e- Sigfiature Printed Name Date tgnature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q\Apphcation FormATOBACCO APP-NonFavor 11-21-19.doc f x�Sga� ltS��A MASSACHUSETTS DEPARTMENT OF REVENUE Force CT-3 Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times.The sale of tobacco �F products to anyone under 18 years of age is prohibited. CAPE COD PACKAGE STORE INC Account ID: CRL-10761789-009 1495 FALMOUTH RD License Number: 2016276480 CENTERVILLE MA 02632-2945 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 revolted for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 r a Commonwealth of Massachusetts Letter ID:L0913236608 Department of Revenue Notice Date:September 4,2018 Christopher C.Harding,Commissioner Account ID:CRIr10761789-009 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO ���I���IIIIIII�II�III���I��IIII�II111111111111111111111so all lflil CAPE COD PACKAGE STORE INC e CAPE COD PACKAGE STORE INC o= 1495 FALMOUTH RD CENTERVILLE MA 02632-2945 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 saw sF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco 7 z MFM 0M. This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. CAPE COD PACKAGE STORE INC Account ID: CRL-10761789-009 1495 FALMOUTH RD License Number: 2016276480 CENTERVILLE MA 02632-2945 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 T�C Department of the Treasury j ►7 Inter11a1 Revenue Service In reply refer to: 0439800000 OGDEN UT 84201-0038 Dec . 04, 2019 LTR 2644C KO 04-11492.12 201712 02 Input by 0409908584 00007624 BODC: WI CAPE COD PACKAGE STORE INC 1495 FALMOUTH RD CENTERVILLE MA 02632-2945 017936 Taxpayer Identification number: 04-1149212 Tax periods:: Dec. 31 , 2017. Form: 1120. Dear Taxpayer : We previously sent you a letter about your inquiry received July 02, 2019. Although we try to respond quickly.,. we often need additional time for research . We can' t provide a complete response at this time because : We need more time to provide you with a complete response to your inquiry. While waiting to hear from us , if you have a balance, you can still make payments to reduce your tax liability and interest charges . To help us apply payments properly, make your check or money order payable to the United States Treasury and provide on each payment: - Name - Address - Social security or employer identification number - Daytime telephone number - Tax year - Tax form Please allow an additional 60 days for us to obtain the information we need and let you know what action we 're taking: You don't ne-ed to do anything else right now. If you have questions, you can call us toll free at 1-800-829-0115. If you prefer , you can write to us at the address at the top of the first page of this letter . When you write, please include a copy of this letter and provide your. telephone number and the hours we can reach :you in the spaces below. Keep a copy of this letter for your records. Your Telephone Number C ) Hours Thank you for your cooperation. Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. RNST BLE Paul J.Canniff,D.M.D. 2-00 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 153 Issue Date: 1/1/2020 DBA: CAPE COD PACKAGE STORE, INC. OWNER: ANDREA PENDERGAST Location of Establishment: 1495 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Q Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY �tt+ r Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. rlwRNSTA11 . John T. Norman " 6 200 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: 153`- Issue Date: 12/20/18 DBA: CAPE COD PACKAGE STORE, INC. OWNER: ANDREA PENDERGAST Location of Establishment: 1495 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: TOBACCO Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES_ FOOD SERVICE ESTABLISHMENT: YEAR. 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: ----- ----- - - -- MOBILE-FOOD: MOBILE-ICE CREAM: Gi FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: j PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �TME�►,ti Town of Barnstable Initials: _ o Date Paid b A.mt-Pd Inspectional Services -heck s t�sreatE. I , r Public Health Division 1639. ON 200 Main Street,Hyannis MA 02601 Thomas A McKean,RS,CHO Office: 508-790-1644 Director of Public Health FAX: 508-790-6304 Fee: $85.00 MAIL TO:TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street RYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT c6d ' ESTA.BL ZiN1WEENT NAME (D/B/A) ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERENT FROM ABOVE) EMAIL �— PHO 'ECJ 6$)775-2,--& ERAL ID;T 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��J —' Date /-Z12-9l Q:1Application Forns7OBA000 APP2019 dob.doex l-d 6066-9LL 909 JO;S e68NOed poo edeo d9Z:Zl 9l tbZ '231811:22p Cape Cod Package Stor 508 775-1901 p.1 Town of Barnstable } • Rgul eatory Services Department M Public Health Division W. 200 Main Street,Hyannis MA 02601 j: Office: 508-7904"4 Thomas A.McKean,RS,CHO FAX: 308-790-6304 Director cf 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 ME REQUIRED FEE OF S85.00 APPLICATION FOR A TOBACCO SALES PERMIT LAST N APPLICANT FIRST NAA'IE AMDLE INITIAL DB/ - STREET ADDRESS ` TEL1kP1E101iE# FID# Do you currently possess a state license to sell tobacco products? Yes V 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). ignature / Date Q:1Appli=ion FormsITOBACCD APP2019 dob.doex Dec 231811:22p Cape Cod Package Stor 508 775-1901 p.2 4ESLIS IS N. TOBACCO SALES Employee Signature Form This form is for official use to indicate that the emploCo se anthis p eb1270 Section receivedent 6 of the understood Chapter 371 of the Town of Barnstable Massachusetts General I.ajvs which describes the nalgelowois Section selling �o9• f thg Town of products to any person under the age of twenty-one (21). Barnstable Board of Health Regulation: Sales to Njinors— 371-9. Sale and Distribution of Tobacco Products. rein,to a person under 1. 1\To person shall sell or provide ahebrnclnc mum legal sales awe iroduct, as defined n the Town of Barnstable The minimum legal sales age. T is 21 years of age. in 2. Identification: Each person selling b means of a ting tobacco ao products, nt-issued po how valiphic shall verify the age of the purchaser } identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employees) received and understoodRe Regulation and 3Chapter the 270 Section 6 of the Board of Health- Prohibition of Smoking -Massachusetts General Laws: ozi Date Printed Name e a ` a r S lA��DL Z 110 t' 1 Printed Name Date Signature � LOU I L b f Printed Name Date i ture Printed Name Date Sign a Printed Name Date Printed Name Date d�.t�- �r DateZ % Signature /Printed Name Q:\Appiication Forms\TOBACCO APP2019 dob.doex Dec 231811:22p Cape Cod Package Stor 508 775-1901 p.3 7 1 ESTABLLSMIENT'S AME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employees) 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. }. n under No person shall sell or provide a tobacco produ g, defined hIIe Town of Barnstable er The minimum legal sales age. The minimum legal sales is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21'years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature Printed Name Date Adz, ed_N 4__ Printed Name Date Signature \ �� ^ \ Y gnature Pri fed Nam Date Date Signature Printed Name , Pri n ed Name , Date afore afar LPrinted N Date r �CfG�r C afore / Printed Name Date C:NUsen1CR4User\AppData\Loca1\\4icrosoftlwindo«s%Temporary interncl Files�content.0utkwk\5NB2LA9117FOBA000 APP2019 dob.docx Dec 231811:22p Cape Cod Package Stor 508 775-1901 p.4 ES ABLISHMENT'S N 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—e 371-9 Sale and Distribution of Tobacco Products._ 1. No person shall sell or provide a tobacco product,as defined herein;to a person under — - _-- - - The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: ignature Printed Name Date Al Signature inted Name Date Signature Printed Name Date Printed Name Date Signature i Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date C�kl sers\CR4User1/'kppDatall.ocal\AvticrosoMWindows\Temporary Internet Files\Content.Outlook\5NB2LA91`,TOBACCO APP2019 dob.docx Town of Barnstable Regulatory Services Department lJ r * anaivsrnsM "tAfffi& Public Health Division Lb RFD!1 200 Main Street, Hyannis MA 02601 \a = Office: 508-7904644 Thomas A.McKean,RS,CHO X 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 2. LAST NAMF40F APPLICANT FIRST NAME MIDDLE INITIAL D/B/ STREET ADDRESS K/5 4 22J-- Zo 6s" /- TEL PH NE # FID# Do you currently possess a state license to sell tobacco products? Yes V 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). ignature V Date Q:\Application Forms\TOBACCO APP2018 dob.docx Establishment TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood sections VII b. and VII c. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of 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 eighteen(18). Below are sections VII b.and VII c.of the Barnstable Board of Health Regulation: SECTION VII-SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors-In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to.a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file,in the office of the employer and retained. Such signed forms must be made available for inspection,during the license holders normal business hours upon request of an agent of the Board of Health. c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age, the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIIb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: (ell l 1 Si e Q Printed N 0 Date( Si tore Printed Name Date Si tur Printed Name Date nt�C`-�_a I(A igna Printed Name Date G- M eI,t Sgna e Printed Name Date ignature Printed Name D to L Signature Printed Name Date Q\Application FormATOBACCO APP2018 dob.doex Establisfiment TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employees) of this establishment received and understood sections VII b. and VII c. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of 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 eighteen(18). Below are sections VII b. and VII c.of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to. a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file, in the office of the employer and retained. Such signed forms must be made available for inspection,during the license holders normal business hours upon request of an agent of the Board of Health. c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age, the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIIb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: St . l Signature Printed Name Date f Printed N Date Printed Name Date Pr jed Na/mJe Date r----, U few Si tur Printed Name Date AVAM Flo 9A� i 2a I e Printed Name k Date//S t /1�a eoks-�4t112 C>1'f e Printed Name Date Q:\Application Forms\TOBACCO APP2018 dob.docx ' e r i,. ' J Establis ent TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood sections VII b. and VII c. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of 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 eighteen(18). Below are sections VII b. and VII c.of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to.a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file,in the office of the employer and retained. Such signed forms must be made available for inspection,during the license holders normal business hours upon request of an agent of the Board of Health. c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a j customer appears to possibly be under 25 years of age,the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIIb. and V 1c. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: v+ L'4p'c'a Sign tore Printed Name Date Signs Printed Name Date Printed Name Date Signature, Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application FormATOBACCO APP2018 dob.docx I `°Ftrok4 TOWN OF BARNSTABLE, HEAXTHINSPECTOR-s Establishment Name: Date: Page: 1 of OFFICE HOURS PUBLIC 0 MAIN STREET DIVISION . 800.-9:30A.M. aE - 3 30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified Ma3q: �e� HYANNIS,MA 02601 MON.-FRI. No Reference R-,Red.Item PLEASE PRINT CLEARLY 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name d Date Type of sec ion p / (,� Operation(s) Routine �lsLLiC +/ l Address / ( ���Lyj �� Risk Foo ervice scoop Level etail Previous Inspection Telephone esi ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP j c )62� In: Other If Inspector w Out: Each violation checked requir s an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating - ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance Com ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items Embar o checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ 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 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 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of ( )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 itical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 g violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view - Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Si atur �.- Print: Self Service f 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) jAssignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained_At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.1](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 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR- 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1](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 HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprout's Not Served* ' P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* 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 5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ery cti-11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source P 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702,11 Frequency of Sanitization of Utensils and Food * 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or [33-202.18 201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F IS sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 0.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g. g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C CommerciallyProcessed RTE Food-140°F* Blue Items 23-30) 3-202.15 Package Integrity ( ) Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 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 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. `oF. TOwti TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date: Page:,of �{ c OFFICE HOURS +'�y� PUBLIC HEALTH DIVISION 80029:30A.M. BARNSfABLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ,639. � HYANNIS,MA 02601 _ _ MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT 508-8624s44 Name �� Datel Type of T f Ins ec ion f OOperation(s) Routine l 1, VwwzQ 61t 1' Address (� '�, Risk ervice e-inspection Level Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) �/� � / Time Bed&Breakfast HACCP Other In: Inspector /� Out: le 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) ❑ J, �+ ��� FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands J ❑ 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) C ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violation b .oC%�/ Critical(C)violations marked must be corrected immediately. (blue&red items) °C7`� 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 o checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (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 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 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's L at re Print: , 2 V 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signa Print: Self Service Wait Service Provided Grease Trap Size - Variance Letter Posted Y N Dumpster Screen? Y N '-_ r-. :..�_�_ _ -�.- �,e_.-_ .ti*-r._..-r __. r- .-- ..+..r->.- ..-•_--�._.� ..�_. .µ.ow .. _-_.._r,-�� --.�-9..<-.:.- �.. __ _' _.- +-._..--_�:.-......_... n -. .+r'-^- -.� ..- .. -.- .�.--, _ s..,. ..-.�--f .. Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 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 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Se ara[ion-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) I 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 1590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* - Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1 g 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 14YF 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate Equipment ( )( ) Pathogens* �� 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * Effective 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf aces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and a ide in ca[er- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. $ 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 P P (Blue Items 23-30) 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* g gr'tY Critical and non-critical violations,which do not relate to the foodborne * 12Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated �) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock [5-2EO3.11 Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13Handwashing Facilities 3-202.18 Shellstock Identification* 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Tags/Records:Fish Products Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 204.11 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 1.008 HACCP Plans . 6-301.12 Hand Drying Provision 29. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 0/_/_ 11Y TOWN OF BARNSTABLE OIL HEALTH INSPECTORS Establishment Name: I00 ! ate: Page: of .06qo OFFICE HOURSPUBLIC 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 MONHYANNIS,MA 02601 -FRI. 08-8 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY �FOMP,a, FOOD ESTlkBLISHMENT INSPE T. N REPORT Name Date Tvoe of Tyne of Inspection Operation(s) Routine Address Risk Fo ice Re-inspection Level e a Previous Inspection Telephone / ' ntial Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General C taint Person in Charge(PIC) I e Bed&Breakfast HACCP Other Inspector i Each violation c ked'requires an explanation on the narrati a pag s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk actors(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 �P ❑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 ' 10 r ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 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 1q ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories b�_M 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 ElYes 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 9 re ardless 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 Tess than 4 non-critical violations 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 Physical Facility (FC-6 590.007 aggrieved b 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 27.Ph y ty )( ) gg y y g g' q violations observed,7 to 8 no critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8non-critical v lation -C. 29.Special Requirements. (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: I s ect '6,signatqe n t: 31.Dumpster screened from public view 91 - Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N If I #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatut q Print: Self Service Wait Service Provided Grease Trap Size Variance.Letter Posted. Y N Dumpster Screen? Y N (I✓ fi Violations related to Foodborne Illness - Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 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 EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to *- Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 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* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef cd-71112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 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,Meal,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 1 p Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail _ _ 3-401.11( )( )( ) 3-201.17 Game Animals* FIT Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g� g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) * 12 Prevention of Contamination from Hands 3-403.11 Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated (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 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance 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 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: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. oF114E i TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: 1 Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. RARNS7'ABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/P F N O CORRECTION Date Verified M6 .� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY 508-862-4644 FOOD ESTABLISHMENT INSP C ION REPORT ti Name Date yRe of Ty9a&Unspection G� Operation(s) Soutine Address Ris Food Service coon ` - ( Level etail Previous Inspection17 Telephone esidential Kitchen Date: Ve Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness 41 Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands J; ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ 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. F] Embargo ❑ Emergency Closure Other: Voluntary Disposal ❑ 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 6=One critical violation and less than non-critical violations 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 establishment operations. If C=2 critical violations and less than9 non-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 mustg 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 anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8non-critical violations=C. 29.yster ements (590.009) Within 10 days of receipt of this order. 30. DATE OF RE-INSPECTION: Inspector's Signature Print: 31. ned from public viewC✓ YV ,Permit Posted? N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Si ature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N ��,�� Dumpster Screen? Y N �i�JJJ Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) _ FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination L 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202:12 Additives* 3-501.15 Cooling Methods for PHFs - -- - - - Cooked and RTE Foods.* * 19.. _ PHF Hot and Cold Holding 2-103.1-1 Person-in---Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) _2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F * 7-102.11 Common Name-Working Containers* _Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* -: Applicants* - -- - - - - - - 3-302.11(A) 7-201.11 Separation-Storage*'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* 590.003(G) Reporting by Person in Charge* _ Contamination from the Consumer Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11). Variance Requirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* q _ 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 ofAdulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water Frarrf Regulated-Sources '" 9 -- Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and * 4-501:111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed Sprouts Not.Served* 3-201.12 Food in a Hermetically Sealed Container Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and MilVProducts* 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. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Eggs Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ep criv 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* 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources 10 Proper,Adequate Handwashing g' P ry Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* Foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g. g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth*. 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercially Processed RTE Food-140°F* Blue Items 23-30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 3-lOLl1 Food Safe and Unadulterated* O g 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From,70'F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 - Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* _ - 8-103A2 1 Conformance with Approved Procedures* S.590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. .*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Miorandi, Donna From: Andrea-CCPS <andrea@capecodpackagestore.com> Sent: Friday,June 28, 2019 4:32 PM To: Bellaire, Dianna Cc: 'Danette Atsalis'; Miorandi, Donna Subject: ,RE: FW: Customer Appreciation BBQ Grill n Chill- Cape Cod Package Store Follow Up Flag: FollowUp Flag Status: Flagged Dianna Thank you very much in the past we've had someone from the TOB Health Division come in yearly to do an inspection-of the cheese.case and everything has been approved, so I look forward to hearing from Donna if need be. Thanks again. Thanks so;much, Andrea L. Pendergast Co-Owner ' Cape Cod Package Store Fine Wine&Spirits CAPE COD Office:508-175-8608 Store:508-775-2065 Shop online at www.capecodpackagestore.com Download our CCPS opp on your Phone Like us on Facebook Follow us on Twitter,Pinterest&Instagram helpmake the earth a greener place. If possible resist Printing this email ancljoin us in saving Paper. From: Bellaire, Dianna [mailto:Dianna.Bellaire@town.barnstable.ma.us] Sent: Friday, June 28, 2019 4:26 PM To: Andrea=CCPS Cc: 'Danette Atsalis'; Miorandi, Donna Subject: RE: FW: Customer Appreciation BBQ Grill n Chill- Cape Cod Package Store Hi; Yes, 10 days is a good time frame for temporary permits. Donna your inspector, will need to inspect your facility. It sounds like:you might still need a retail food permit. I copied Donna on this matter and I will let her know on Monday what was discussed too. If so, we will need to renew your retail food permit if Donna believes you require one. Thank you.: Dianna Bellaire Permit Technician Town of Barnstable 1 ' 1 Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire @town.barnstable.ma.us i From: Andrea-CCPS [mailto:andrea@capecodpackagestore.com] Sent: Friday, June 28, 2019 4:13 PM To: Bellaire, Dianna Cc: 'Danette Atsalis' Subject: RE: FW: Customer Appreciation BBQ Grill n Chill Importance: High Dianna Thanks for the clarification re: any food service outside and we'll be sure to get a permit for this event in the future. What's the typical time frame that we should allow for applying for this permit? Also, In the:past our permit included our cheese case in the store, so I just want to be certain that this is still the covered with the state code changes. As when I dropped off our license renewal last year I thought it was told to me that yes indeed we'd be all set and this was covered. If this isn't the case please let us know what we need to do to make sure we are following the current codes. Thanks somuch, Andrea L. Pendergast Co-Owner Cape Cod Package Store Fine Wine&Spirits wE�Shf:igti' GXPE}"COr. PA k.,tCrai`Ce Office:508-775-8608 Store:508-775-2065 Shop online at www.capecodpackagestore.com Download our CCPS opp on your Phone Like us on Facebook Follow us on Twitter,Pinterest&Instagram Help make tke earth a greener Place. If Possible resist printing this email andjoin us in saving Paper. From: Bellaire, Dianna [mailto:Dianna.Bel laire@town.barnstable.ma.us] Sent: Friday, June 28, 2019 3:34 PM To: Andrea=CCPS Cc: 'Danette Atsalis' Subject: RE: FW: Customer Appreciation BBQ Grill n Chill Hi; Your may have had a retail food permit in the past for candy bars and soda but,you never had a food service commercial kitchen permit and if you cook outside to the public, it is not covered by a commercial kitchen. Your current permit is now TOBACCO ONLY because the state code changed last year and we no longer have to give permits for candy 2 bars, soft drinks or foods that don't require a freezer/fridge. So, if you review the attached permit you gave me, it states tobacco permit. Anyone who cooks outside and serves to the public, is required to get a permit. This includes restaurants of any kind too. 1 hope that clarifies it. You can always email me if you have any questions, now that you have my email. Thank you and have a nice weekend. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire @town.barnstable.ma.us i From: Andrea-CCPS [mailto:andrea@capecodpackagestore.com] Sent: Friday, June 28, 2019 3:02 PM To: Bellaire, Dianna Cc: 'Danette Atsalis' Subject: RE: FW: Customer Appreciation BBq Grill n Chill Importance: High Hi Dianna My office manger forwarded me the email you sent her this morning re: our event yesterday at the store. I was unaware we needed a Temporary Food Permit for our event as I thought our current Food Establishment Permit covered this, so our apologies. The permit documentation in 2018 stated for Food and this last year when I asked why it wasn't included I was told that the permitting process had changed but we were still covered for it. Thanks for letting us know for future reference. Have a Happy 4th of July ! Thanks so much, Andrea L. Pendergast Co-Owner Cape Cod Package Store Fine Wine&Spirits aa;3c x;� lot CARE CV) tACKxGkS OR:f Office:508-775-8608 Store:508-775-2065 Shop online at www.capecodpackagestore.com Download our CCPS app on your Phone Like us on Facebook Follow us on Twitter,Pinterest&Instagram EA Help:make the earth a greener Place. If Possible resist Printing this email andjoin us in saving Paper. From: Bellaire, Dianna [mailto:Dianna.Bellaire town.barnstable.ma.us] Sent: Friday, June 28, 2019 9:23 AM 3 3 To: office(abcapecodpackagestore.com Cc: Bellaire, Dianna Subject: Customer Appreciation BBQ Grill n Chill To Whom It May Concern; I was notified that you had a BBQ Grill day at your store for customers. If you are serving food to the public,you are REQUIRED to apply for a temporary food permit at the Town of Barnstable.A one day permit is$40 and 2 days is$50. It doesn't matter if food is free. You are not a food service establishment. I am giving you this information as a one-time courtesy. Please apply for permits in the future. I've attached a copy of the Town of Barnstable Temporary Food Policy for your review. Sincerely; Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe! CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe! CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe! 4 Olive Oil & Balsamic Vinegar bottling Page 1 of 2 Miorandi, Donna From: Andrea Pendergast[andrea@capecodpackagestore.com] Sent: Friday, October 14, 2011 7:25 PM To: Miorandi, Donna Cc: 'Jack Pendergast Jr.'; 'Danette Atsalis'; Bill@capecodpackagestore.com; 'diane' Subject: RE: Olive Oil & Balsamic Vinegar bottling Importance: High Hi Donna, Here are the answers to your questions: Good Morning Andrea: Sorry for the delay in,getting back to you. I have been doing research on this and it has been quite busy here this week. I have a few questions that I need clarified. 1. Are the customers filling the bottles themselves? Or are they specifically refilled by an employee? An employee is filling u the empty brand new bottle to be sold and then an employee is refilling the bottle 9 P pY9 that the customer brings back with them to refill. The reason for this is to reduce glass waste, only selling one bottle per customer and then charging them for the oil when they bring there bottle back in. The customers have been extremely responsive to the refill process. 2. When the customer comes in with used empty bottle do they refill that same bottle or do they receive a new replacement bottle that has been washed and sanitized in your dishwasher? The employee refills the same bottle that they originally purchased. (On a side note, this is common practice with olive oil for instance I use to buy the large jug of olive oil in the supermarket and then keep refilling an empty bottle at home.) 3. How many empty clean bottles are on site and where are they stored? The empty brand new bottles come packaged from the supplier in a sealed box of 12bottles per box and they get stored in the back in there box until an employee fills them and puts them on the shelf for sale. 4. Have you obtained a maximum registering thermometer yet? I placed an order with the company you gave me unfortunately they've been away on vacation so it won't ship till next week. If you could answer these questions I would greatly appreciate it. In addition, if you are doing tastings accompanied by open food, i.e. cheese, crackers, etc. then someone on site will have to be servsafe trained. I can get you info on obtaining that servsafe certificate. In response to the servsafe certificate needed for serving cheese/crackers during tastings, I would like to discuss this further with you. I have no problem getting the servsafe certificate for the reason-mentioned, but think that it's an area that needs further exploration. It is my understanding that in the state of MA all wine/liquor stores who have alcohol tastings have to by law serve food during the tasting and most all of them serve cheese and crackers. I know we've been doing this practice for 10+ years if not longer in the store, so that's where my question stems from. I'll be available by phone to discuss further on Mon. if you'd like. Thanks and looking forward to speaking with you. Andrea Pendergast 10/18/2011 Olive Oil & Balsamic Vinegar bottling Page 2 of 2 Cape Cod Package Store, Inc. Fine Wine, Beer & Spirits 508-775-206.5 Sign up for our monthly E-newsletter at www.capecodpackagestore.com AHelp make the earth a greener place. If possible resist printing this email and join us in saving paper. From: Miorandi, Donna [mailto:Donna.Miorandi@town.barnstable.ma.us] Sent: Thursday, October 13, 2011 11:10 AM To: andrea@CapeCodPackageStore.com Subject: Olive Oil &Balsamic Vinegar bottling Good Morning Andrea: Sorry for the delay in getting back to you. I have been doing research on this and it has been quite busy here this week. I have a few questions that I need clarified. 1. Are the customers filling the bottles themselves? Or are they specifically refilled by an employee? 2. When the customer comes in with used empty bottle do they refill that same bottle or do they receive a new replacement bottle that has been washed and sanitized in your dishwasher? 3. How many empty clean bottles are on site and where are they stored? 4. Have you obtained a maximum registering thermometer yet? If you could answer these questions I would greatly appreciate it. In addition, if you are doing tastings accompanied by open food, i.e. cheese, crackers, etc. then someone on site will have to be servsafe trained. can get you info on obtaining that servsafe certificate. Thank you Donna Miorandi, R.S. Health Inspector Town of Barnstable 10/18/2011 Message Page 1 of 2 Miorandi, Donna From: Miorandi, Donna Sent: Wednesday, October 19, 2011 9:59 AM To: 'Andrea Pendergast' Subject: RE: Olive Oil & Balsamic Vinegar bottling Hi Andrea: Thanks for your answers. You are all set because it is employee involvement. If that were not the case then, it would be different requirements. I spoke to my boss and he said we are giving a ocal exemption to the servsafe requirement when it is just crackers and cheese at a wine tasting. Therefore, you are not required to have a servsafe certificate. Thanks for your time and attention to this matter. Any future questions please don't hesitate to call or e- mail me. Donna -----Original Message----- From: Andrea Pendergast [mailto:andrea@capecodpackagestore.com] Sent: Friday, October 14, 2011 7:25 PM To: Miorandi, Donna Cc: 'Jack Pendergast Jr.'; 'Danette Atsalis'; Bill@capecodpackagestore.com; 'diane' Subject: RE: Olive Oil &Balsamic Vinegar bottling Importance: High Hi Donna, Here are the answers to your questions: Good Morning Andrea: Sorry for the delay in getting back to you. I have been doing research on this and it has been quite busy here this week. I have a few questions that I need clarified. 1. Are the customers filling the bottles themselves? Or are they specifically refilled by an employee? An employee is filling up the empty brand new bottle to be sold and then an employee is refilling the bottle that the customer brings back with them to refill. The reason for this is to reduce glass waste, only selling one bottle per customer and then charging them for the oil.when they bring there bottle back in. The customers have been extremely responsive to the refill process. 2. When the customer comes in with used empty bottle do they refill that same bottle or do they receive a new replacement bottle that has been washed and sanitized in your dishwasher? The employee refills the same bottle that they originally purchased. (On a side note, this is common practice with olive oil for instance I use to buy the large jug of olive oil in the supermarket and then keep refilling an empty bottle at home.) 3. How many empty clean bottles are on site and where are they stored? The empty brand new bottles come packaged from the supplier in a sealed box of 12bottles per box and they get stored in the back in there box until an employee fills them and puts them on the shelf for sale. 4. Have you obtained a maximum registering thermometer yet? I placed an order with the company you gave me unfortunately they've been away on vacation so it won't ship till next week. 10/19/2011 Message Page 2 of 2 If you could answer these questions I would greatly appreciate it. In addition, if you are doing tastings accompanied by open food, i.e. cheese, crackers, etc. then someone on site will have to be servsafe trained. I can get you info on obtaining that servsafe certificate. In response to the servsafe certificate needed for serving cheese/crackers during tastings, I would like to discuss this further with you. I have no problem getting the servsafe certificate for the reason mentioned, but think that it's an area.that needs further exploration. It is my understanding that in the state of MA all wine/liquor stores who have alcohol tastings have to by law serve food during the tasting and most all of them serve cheese and crackers. I know we've been doing this practice for 10+years if not longer in the store, so that's where my question stems from. I'll be available by phone to discuss further on Mon. if you'd like. Thanks and looking forward to speaking with you. Andrea Pendergast Cape Cod Package Store, Inc. Fine Wine, Beer & Spirits 508-775-2065 Sign up for our monthly E-newsletter at www.capecodyackagestore.com Help make the earth a greener place. If possible resist printing this email and,join us in saving paper. From: Miorandi, Donna [mailto:Donna.Miorandi@town.barnstable.ma.us] Sent: Thursday, October 13, 2011 11:10 AM To: andrea@CapeCodPackageStore.com Subject: Olive Oil &Balsamic Vinegar bottling Good Morning Andrea: Sorry for the delay in getting back to you. I have been doing research on this and it has been quite busy here this week. I have a few questions that I need clarified. 1. Are the customers filling the bottles themselves? Or are they specifically refilled by an employee? 2. When the customer comes in with used empty bottle do they refill that same bottle or do they receive a new replacement bottle that has been washed and sanitized in your dishwasher? 3. How many empty clean bottles are on site and where are they stored? 4. Have you obtained a maximum registering thermometer yet? If you could answer these questions I would greatly appreciate it. In addition, if you are doing tastings accompanied by open food, i.e. cheese, crackers, etc. then someone on site will have to be servsafe trained. I can get you info on obtaining that servsafe certificate. Thank you Donna Miorandi, R.S. Health Inspector Town of Barnstable 10/19/2011 Page 1 of 1 Miorandi, Donna From: Bernazzani, Diane(DPH) [diane.bernazzani@state.ma.us] Sent: Tuesday, October 11, 2011 8:08 PM To: Miorandi, Donna Cc: Zulkiewicz, Jane; Foley, Kim (DPH) Subject: {Disarmed) RE: Repacking Hi Donna, This same issue was discussed at FEAC a few years ago and the decision was made that based on Food Code section 4-603.17 Returnables, Cleaning for Refilling the establishment should Diane Bernazzani, REHS/RS, CP-FS Food Vulnerability Assessment& Training Coordinator MDPH Bureau of Environmental Health Food Protection Program 305 South Street, Jamaica Plain, MA 02130 phone: 617-983-6765 fax: 617-983-6770 diane.bernazzaniCa.state.ma.us MailScanner has detected a possible fraud attempt from. "email.state.ma.us" claiming to be htti):Ilw\rvw.mass.gov/dr)h/foo Blog: MailScanner has detected a possible fraud attempt from "em.ail.state.ma.us" claiming to be http://publichealth.blog.state.ma.us From: Miorandi, Donna [mailto:Donna.Miorandi@town.barnstable.ma.us] Sent: Tuesday, October 11, 2011 4:03 PM To: Foley, Kim (DPH) Cc: Zulkiewicz, Jane Subject: Repacking Hi Kim, I have a question on something I came across last week at a liquor store that just holds a packaged retail permit with us. Upon inspection I notice a 5 gallon jug with a spigot that contains olive oil. Another one of a smaller size that has balsamic vinegar in it-also with a spigot. I inquired about what was happening here and they informed me that in the back-small non-compliant kitchen-they have gallon size jugs of olive oil and vinegar. They take the jugs and open them up and pour them into this bigger jug with spigot that is out on the customer display floor. Same for the balsamic vinegar. They then fill from the spigots into glass bottles-16 oz. size the olive oil and cap it. Same is done with the vinegar. These are then sold and when the consumer is done with the product they can come in and refill the 16 oz. Have they crossed the boundary from packaged retail to something else?? Like food service?? Please give me your guidance on this since it is a first for me in a liquor/package store. Donna Miorandi, R.S. Health Inspector Town of Barnstable 10/19/2011 Repacking Page 1 of 1 Miorandi, Donna From: Bernazzani, Diane ;DPH) [diane.bernazzani@state.ma.us] Sent: Tuesday, October 11, 2011 4:59 PM To: Miorandi, Donna Cc: Zulkiewicz, Jane; Foley, Kim (DPH) Subject: {Disarmed) RE: Repacking Hi Donna, This same issue was discussed at FEAC a few years ago and the decision was.made that based on Food Code section 4-603.17 Returnables, Cleaning for Refilling; the bottles need to be washed at the establishment before re-filling. It is still considered to be retail but it is a bulk food item. If you have any further questions, please feel free to contact me at 617-983-6765 or via e-mail. Diane Bernazzani, REHS/RS, CP-FS Food Vulnerability Assessment&Training Coordinator MDPH Bureau of Environmen-al Health Food Protection Program 305 South Street, Jamaica Plain, MA 02130 phone: 617-983-6765 fax: 617-983-6770 diane.bernazzani(@state.ma.us MailScanner has detected a possible fraud attempt from "email.state.ma.us" claiming to be http://www.mass.-gov/dph/fpp Blog: MailScanner has detected a possible fraud attempt from "email.state.ma.us" claiming to be http://Publichealth.blog.state.ma.us From: Miorandi, Donna [mailto:Donna.Miorandi@town.barnstable.ma.us] Sent: Tuesday, October 11, 2011 4:03 PM To: Foley, Kim (DPH) Cc: Zulkiewicz, Jane Subject: Repacking Hi Kim, I have a question on something I came across last week at a liquor store that just holds a packaged retail permit with us. Upon inspection I notice a 5 gallon jug with a spigot that contains olive oil. Another one of a smaller size that has balsamic vinegar in it-also with a spigot. I inquired about what was happening here and they informed me that in the back-small non-compliant kitchen-they have gallon size jugs of olive oil and vinegar. They take the jugs and open them up and pour them into this bigger jug with spigot that is out on the customer display floor. Same for the balsamic vinegar. They then fill from the spigots into glass bottles-16 oz. size the olive oil and cap it. Same is done with the vinegar. These are then sold and when the consumer is done with the product they can come in and refill the 16 oz. Have they crossed the boundary from packaged retail to something else?? Like food service?? Please give me your guidance on this since it is a first for me in a liquor/package store. Donna Miorandi, R.S. Health Inspector Town of Barnstable 10/19/2011 Massachusetts Department of Environmental Protection Bureau of Resource Protection WELL DRILLER Please specify work performed: Address at well location: New Well Street Number: Street Name: .r '~ 1495 _( FALMOUTH ROAD Please specify well type: Building'Lot#: Assessor's Map#: Irrigation Assessor's Lot#: ZIP Code: Number Of Wells: 02632 City/Town: Well Location BARNSTABLE In public right-of-tray; GPS i • Yes No North: West: 41.65720 170.34208 Su bd ivision/Property/Description: Mailing Address: • click here if same as well location address Property Owner: Street Number: Street Name CAPE COD 'EST 1495 _ FALMOUTH ROAD City/Town: State: Engineering Firm: 1BARNSTABLE MASSACHUSETTS ZIP Code: ----------� 02632 Board of health permit obtained: • Yes • Not Required Permit Number: Date Issued: W2010 23 9/13/2010 °— 2E" #I .»I g M Page 1 of 1 Massachusetts Department of Environmental Protection LP ` Bureau of Resource Protection—Well Driller Program`; Well Completion Reports(General) WELL DRILLER - GENERAL WELL FORM DRILLING METHOD- Overburden Bedrock Auger --Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop In Extra fast or slow Loss or addition of (ft) drill stem_ drill rate fluid 0 20 Fine To Coarse Sand Brown Yes:. Fast Slow', Loss Addition 20 Fine Sand lerownSlow; Loss Addition' 35 45 Fine To Coarse Sand Brown Yes' Fast Slow; Loss Addition: WELL LOG BEDROCK LITHOLOGY Visible Extra From Drop in Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (ft) drill stem drill rate fluid Staining Chips Choose Code • Yes Fast Slow; Loss Addition Yes': ADDITIONAL WELL INFORMATION Developed_ „ Yes Noj r Disinfected Yes _.._ No Total Well Depth 45 Depth to Bedrock Fracture Surface Seal Type None Enhancement Yes No; CASING Is Casing above ground?i From To Type Thickness Diameter Driveshoe 0 41 Polyvinyl Chloride hedule 40 4 Yes; SCREEN No Screen: From To Type Slot Size Diameter 41 45 Stainless Steel Well Point 0.012 WATER-BEARING ZONES • DRY WELL From To Yield(gpm) 22 , - -_ 45 F1 5 _ PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Horsepower Submersible 1 Pump Intake Depth(ft) 41 _T Nominal Pump Capacity(gpm) 20 Page 1 of 2 I -- Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Wel Completion Peports(General) i ANNULAR SEAL/FILTER PACK _ Water •_ From To Material 1 Weight Material 2 Weight(gal) Batches Method Of Placement Choose Material Choose Material Choose One-- WELL TEST DATA Pumping Time Time To Recovery(ft Date Method Yield(gpm) Level (ft 9l28/2010 Constant Rate Pump 15 Pumped 00 123 OeOcover BGS BGS) WATER LEVEL Date Measured Static Depth BGS (ft) Flowing Rate(gpm) 9/28/2010 ! 22 I COMMENTS - __. _--i •- _ ..._____,__ , WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. Driller THOMASEDESMONDIII ! Registration# 764 Supervising Driller Signature DESMONDIII,THOMAS Firm DESMOND WELL DRILLIN Rig Permit# 100 Date Job Complete 9/28/2010 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. Page 2 of 2 N a 7��r`,. COMMONWEALTHd .OF lYitla7SACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 4b �1 W nT LE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Ct iM pu+- \ ► 1 tC_ ` �r Owner's Name: �d QCk-OQP Owner's Address: Date of Inspection: /—R.t Name of Inspector,(please print) Company Name: William L. Robinson Septic Service Mailing Address: P O Box 1089 Centerville. MA Telephone Number: ts081 77s-8776 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to section 15340 of Title 5(310 ChIR 15.000). The system: !/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails ' Inspector's Signature: lti.; , — Date: !—X A—O it The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to;the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/152000 page 1 a Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:) 0wner. S�V a Z 1 P,r Q p9a's A- Date of lnspectiow --IL Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.1304 exist.Any failure criteria not evaluated are indicated below. Comments: B. stem Conditionally Passes: ne or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer y ,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The eplic tank is metal and over 20 years old*or the septic tank(whether meta;or not)is structurally unsound,c ibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tan k is replaced with a complying septic tank as approved by the Board of Health. •A metal so ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating t iat the tank is less than 20 years old is available. ND expla' Ob ervation of sewage backup or break out or)ugh static water level in the distribution box due to-broken or obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval !Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND ex lain: e system required pumping more than 4 times a year due to broken or obstrtxxed pipe(s).The system will pass ins ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is zr wvcd ND explain: f Page 3 o1 I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Nq5 1—lam Gy)00+t' -\ i�oc�d .E o; 1 ie— Owner.. C-C t CK SiDce Date of Inspection: / " 3--4 5' - C ,Further Evaluation is Required by the Board of Health: Conditions-exist which require further evaluation by the Board of Health in order to determine if the system is fail' g to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the s stem is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh 2. ys1cm will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syst in is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply weft. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frorrl a private water supply well- Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered_A copy of the analysis must be attached to this form. i Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: `HC(S 'PP�r, P_`14�cs7,r Owner: C C:. PLLCC-QC�2 SSE Date of Inspection: i D. tem Failure Criteria applicable to all systems: You m st indicate"yes"or"no"to each of the following for all inspections: Yes Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outtet invert due to an overloaded or clogged SAS or cesspool — Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. .Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 f ct from a private eater supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free-from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy or the analysis must be attached to this forma (Yes/No)The system fails.I have determined that one or more of.the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: T be considered a large system the system must serve a ficility with a design flow of 10,000 gpd to 15,000 g must indicate either"yes"or"no'to each of the following. { following criteria apply to large systems in addition to the criteria above) yes o Ole system is within 400 feet of a surface drinking water supply ___. _ the system is within 200 feet of a tributary to a surface drinking water supply e system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped one I I of a public water supply well If you have swered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in S ion D above the large system has failed.The u wner or operator of any large system considered a significant t eat under Section£or failed under Section D shall upgrade the system in accordance with 3 10 CMR 15.304.The -stem owner should contact the appropriate regional office of the Department. 4 Pag4 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop rty a Address: cc-,a Owner: CC--N-Ct_C. S. . Q. Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No , Pumping information was provided by the owner,occupant,or Board of Health _ _✓ Were any of the system components pumped out in the previous two weeks 7 f_ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as NIA) Y — Was.the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank:manholes uncovered,opened,and the interior of the tank inspected for the condition of.the baffles or tees,material of construction,dimensions.depth of liquid,depth of sludge and depth of scum? = r Was the facilityowner and occupants if different from owner( p )provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CI AR 15.302(3)(b)J 5 Page 6 of 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1yC15 Owner: C L PC_C cC1 �e Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): d Number of bedrooms(actual): 0 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: O Does residence have a garbage grinder(yes or no): it-o Is laundry on a separate sewage system(yes or no): ¢o jif yes separate inspection required] Laundry system inspected(yes or no):- Seasonal use:(yes or no):_A!:�J _ Water meter readings,if available(last 2 years usage(gpd)): _-:)00? - Sump pump(yes or no): A 0 a GAL to _ 7 Cf p Last date of occupancy: /A x.-o COMM ERCIAL/INDUSTRIAL Type of establishment: S 2. Design flow(based on 310 CMR 15.203): G q n gpd Basis of design flow(seats/persons/sgft,etc.):_.r•v Grease trap present(yes or no):i-d Industrial waste holding tank present(yes or no):wa Non-sanitary waste discharged to the Title 5 system(yes or no):A-o0 Water meter readings,if available: 40 .4,-p Last date of occupancy/use:/-Z s.-o S OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):"e, If yes,volume pumped: it e 4 gallons-How was quantity pumped determined? !A G. S Reason for pumping: 7 A,,s G rr.eo peel• .s TY$E OF SYSTEM Septic tank,distribution box,soil absorption system mgle cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) —Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other describe : Approximate age of all components date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Paf;e 7 of I I OFFICIAL INSI'1?CTION FORAI—N0'r I101t VOLUNTARY ASSESSAIENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTIOM ORAI PART C —,SYS"I'M INFORMATION(continued) Proptrly Address; lt,gJ Ditit of Inspcolon; BUILD G 5LNVLR(lucatc un site plan) Dcpdw Blow grade; Matcri Is of construction:_cast iron _40 PVC_vUlcr(explain): Distan c front privalc water supply WC11 or suction Zinc:_ Collin cuts(on condition of joints,vcnling,evidence of icakage,etc-): SCPTIC TANK;✓(locate un site plan) Dcptl►below grade: /to" Material of construction: %0(Vrlerele metal fiberglass__lrvl)eU►ylcne _ntl►cr(cxplain) — If tank is metal list age:_ Is age cunflnncd-by a Ccitiricalc of Cungrliance (ycs ur nu):i(atlach a cup),of certificate) 011nenSlOnS: rG G Sludge depth: d Distance front ToP of SluJgc lu button►of uutict icc of ballic: V 9 Sctun tl►ickncss: O Distance from top of scum Iu top of outlet ice or baflle: Distance Dorn buitun►or scum lu buuun►of uutict tcc or ba(I- ��3 l lo% <cctc diincnsiuns dctcru►incd:O V;46, _o rt l A Comments(oil pumping ieuarrmcrtdatiuns,inlet and outlet i ba(11e�idiiicn, sit uciw al it it ebrity,liquid Ic%.cIs as ielatcd to outlet invctl,Evidence of leakage,etc.): GREASE i{ ';^(locate un site plan) Depth below adc:_ Malcrial of a nsUudiun:_cuucictc rectal_tibclglass`pulyckitylenc ouhct (cl,plain): — Dinicasions Sctun tllic toss: Distance[out lop of stunt to toil of outlet Ice or baflic:_ Distance Onl bottom of scuilt to bolluill of uutict ice Or banllC: Date of I st pumping: CullumIs(oilpumping IcCunuoe lid atiuns,inlet and vullel ice ur baffle cunditic--:i,stiucluial imcgiily,liquid lc%-CI3 as rclat 10 01111cl int•cil,ct-idrn(c 01 Icaka fc,cic.): 7 l ,'age 8 of I OFFICIAL INSIOEM'JON DORM—NOT bolt VOLUN'I'AIII' ASSL•'SSNILN'I'S SUBSUIVACL SEWAGE' DISPOSAL SYSTEM 1NSl1l:C'PI0N F01ti11 PAIU* C SYSTLAI 'NFORAIATION(continued) Property Address: I yC(Gj tMCk�`I-l� et Owncr: C (( .0 llatc of lospcclloo: TIGHT or 110 UING TANK:_(task must be pumped at time of inspectivn)(lucale un silt plan) Dcplh below adc: 1`tatctial of co stru�►ion:_—curtctcic_rncta{—fiberglass_Jro{yctl►ylcnc othcr(cxplain): Dimensions: Capacity: alluns Design Flo _ _,&allunslday Alarm prc n1(ycs or no): Alarm Icv I: Alarm in %vurkin urdcr rnptg: 6 (J'cs ur nu): Date of l+pu Cununcnts(condition of alarm and ffuat sr s tt tires,etc.): DISTKIUUTION BOX: Zifpresent"rust be opcncd)(localc on site plan) Depth of liquid level above outlet im•crt: Continents intnjo or oW of box,etc.):(Hole if box is level and distrib leakage ution to outlets equal;all)-evidence of solids ctwrryover,any evidence of 7 o K 1'Upli'CIIAh1 Lit:.._—(lucate on site plan) Pumps in w -ing order(yes or no)- Jig Alarms in orking order(ycs or no): Couu"cnl (nvle eonditiou of pump clw"►bcr,«u►diliun of pumps arrd alrlrurte"ances,e(c.): Pagg 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ��g� -�IOL' f1 irC�CCi , v;1 t✓ Owner: CC Date of Inspection: i--Jt o SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Ty leaching pits,number: j leaching chambers,number: leaching galleries,number. leaching trenches,number,length: aching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs_of hydraulic failure,level of pondin„damp soil,condition of vegetation, etc.): ° CESSPOOLS:_3_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: I Depth of scum layer: 6 ' Dimensions of cesspool: S /—( d c o G.i® 1 Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition o soil,signs of hydraulic failure level of ponding,condition of vegetation,etc.): �� QF (�•. � A i i�.o 7�.. f, -- PRIVY: (locat on site plan) Materials of cons ction: Dimensions: Depth of solid Comments(n to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4Q� �C5C��0 vt� -t � - 1ti e a Owner:CC' Date of Inspection: 1-- 2 i—a SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet-Locate where public water supply enters the building. 74-6 10 ;Page•I l,of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION(continued) Property Address: qrJ �th ;i-YiL:4H\ ZoC-C! p P` ��C ►^Vi (i£ Owner. CL t CtC.i(_CGC�R Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells cc Estimated depth to ground water i feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting propertylobservation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: i ll t � z r t TM: Mothers Against Drunk Driving 3821 Route 28, Box B7 • Marston Mills, MA 02648 • (508) 420-0200 - FAX: 420-1339 • E-mail:maddcci@capecod.net CAPE COD AND ISLANDS CHAPTER March 7, 2001 Cape Cod Package Store Attn: Store Owner 1495 Falmouth Road Centerville,MA 02632 Dear Store Owner: The MADD Cape Cod and Islands Youth In Action team recently conducted an alcohol purchase survey in Myers. What is an alcohol purchase survey? An alcohol purchase survey is not a"sting." It is a project completed by,high school age students who recruit a legal, `youthful-looking" buyer to enter a package store, attempt a purchase and see if they are asked for identification. The Youth In Action members are doing this project as an educational awareness piece forour community on the accessibility of alcohol and the enforcement of checking identification of young looking adults. All information is forwarded to the police department. Here are the specifics from our visit to your location: Date:February 23, 2001 Time: 3:53 PM Age of decoy: 22 Gender of decoy: Female Type of alcohol:Mike's Hard Liquor Clerk's approx. age: 60 Clerk's gender: Male Ask for age:No Ask for ID: Your store carded our "youthful"buyer.. Outcome of sale: The purchase was denied! Thank you for your attention and vigilance-to carding`youthful"buyers. Keep up the good work. Your efforts will help save lives. If you have any questions please contact me at(508)420-0200. Sincerely, PL Christine Bates E.A-PRq�Fpi a FP Y .10563 ® �� �r r►e 3 e! �„m I I I I i I I I I I — • e F—WM,j I Iji I I I I I j I I i I j I _ i u III I I I I I I I I I I I I III I - �--T-- - t- f cd j l I I I I I I I I --- — — --- -- E 1 1 I I I I 1 1 I I ro..�Ta..cE � I s• �js,�.{ � "' IN I Q- ------'r---- — —---'----------- ---�-- - --� ...e —f--#---•—. r I ljl ®.2 I I j i I I I I p I H N 1 1,1 I I NlDEMPf Q1 I I I Y .m m. I I I I I j j f I _ FMaoaiaor, I FIRST FLOOR PLAN y„v<•.r4 m.rcra ti A 1 .1 SAWO VASC-48 Page 1 of 1 Home Wa 0 1 .L f l �f Since1949 n t Standard-Versatile Open Air Merchandisers-Lighted Sign VASC 48 DWit l White Exterior,White Interior-Narrow width&depth for easy placement in retail f Refrigeration System Environmentally responsible refrigerant used in all systems. 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Warranty 1 year parts and 1 year limited labor warranty. www.coldstreamproducts.com Division of Cas-Lin Industries http://coldstreamproducts.com/VASC-48.html - 11/9/2010 J C�P��' ✓ � ��� u�� �' ) Nb. -J--- -- - - -- Fee- -- ------------- BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicat ion for Well Congtruct ion Permit Application is hereby made for a permit to Construct (44, Alter ( ), or Re ( ividual Well at: Location — Address kssessors Map and Parcel Owner Address Installer — Driller -��� d} LttTR1LL�IV'G;IN�, _ 5 RAYBER ROAD,BOX 2783 Type of Building ORLEANS,MA 02653 Dwelling (508)240-1000 Other - Type of Building ��1V.c�3__�✓�-G��. No. of Persons-_ --_----------------- Type of Well--�—_� Capacity��— -- — -_— Purpose of Well--�Z '—G wr18 --�_—_ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The i Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until ertificate.of Compliance has been issued by the Board of Health. 2v� Signe C-Z — 2 _— / _ date Application Approved By. — ® ___ _ _ / da Application Disapproved for the following reasons: —=--___ -___ date----- Permit No. — Issued----- --- ------ -__-------------- date BOARD OF HEALTH DESMOND WELL DRILLING, INC. OWN OF B A R N S T A B L E 5 RAYBER ROAD,BOX 2783 ORLEANS,MA 02653 ((certificate Of Compliance (508)240-1000 THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by - ------------- —--- -____ - --- -- ---- Installer athas been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated— ------_-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE __ _— _ Inspector tf ---- -1___ ----Zk-j------ - - BOARD OF HEALTH TOWN OF BARNSTABLE Zipplicat ion Ar;Well Con5tructionVermit Application is hereby made for a permit to Construct (tf, Alter ( ), or Rep it ( r) nAn ividual Well at: Location — Address Assessors Map and Parcel Owner Address it. .t o Jet c� c�9' Installer — Driller Address Type of Building Dwelling--_------_—_-- —___-- '' - O e of Building -Trw L ____-_---_---_--Other - Type g----------- - No, of Persons-- Type of Well--� V __ _—_ Capacity f A4 1. — —_—_ YP P Y------ ----------- Purpose of Well 7 -6-41 6 G4T 6—OL —_—_ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until ertificate.of Compliance has been issued by the Board of Health. Signe' date Application Approved By / f date Application Disapproved for the following reasons: date -- Permit No. — __ Issued-- --------------_-- ------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by--- — ----- ---- -— --- Installer at_ --- —------------------------- -- --- ---has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. —-----------Dated---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE -- ___. _ Inspector------------- BOARD OF% HEALTH TOWN OF BARNSTABLE Vell Con0ruction3permit -� No. 2i -ao 00 Fee- Permission is hereby granted --- ------------------------- to Const t Alter ,/or air ( yan In ' i 1 We 1 t sheet as sho on the application fob Well Construction Permit `-d -L -'-No.- --------- Dated---a -.—�_ — ------------- --- 3oard ggealth- DATE ( � v No. I � r IU 1 O Fee THE COMMONWEALTH OF MASSACHUSE TS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RPOicatiOR for �D*05al *pgtem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Add�ss or Lot No.. O �s Name,Address, d Te�C\�/I�fq. "1� �"KQ MD c� ��� v ► �ii'`ate„/_, (_�"c®"� WIr Assessor's Map/Parcel Installer's Name,Address and Tel.No.WV'��-- 7 75 13 (0 Designer's Name,Address and Tel.No. 6 Gov Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil C�-C�Nature of Re airs or Alteratio s(Answer when applicable) '. 0 -- _ c Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage d posal syMm in CO accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until Certifi of m Compliance has been issued by this Board o H ftlth. Signed 0 A p ate `G; Application Approved by AV Date Application Disapproved by: Date for the following reasons Permit No. jZ Date Issued ---=--7---=—t------------------- . .�.«.. •I .� � ,_....-..� • - o- '+...:wsr'"'_ `..•:..�.,Lt-yk.ys�+x:.�,.gr„ „ .... ,.- y±,.w -"'T`.:: ,�?.. � , .—r:.t;. �„t. No. . Fee �V h THE COMMONWEALTH OF MASSACHUSE TS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for`Migoar *pgtem Cott.5truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components F ocatisAdV or Lot No.- '�.s� J . �� O ner's AddressLo. & T �T Assessor'sMap/Pazcel Installer's Name,Address,and Tel.No 7 Designer's Name,Address and Tel.No. o 40t 6.UVC,1 &-\-(0CLk1Ct Type of Building: t Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building f No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) I/ gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank ( U Type of S.A.S. Description of Soil Nature of Repairs or Alteratio s(Answer when applicable) - l Q.�Poo 1 l,O 1'�' y k SZ50+ Q Sef r\3 Date last inspected: Agreement: f` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in, accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board pf H,dalth. Signedff J //f O !?0 Date Application Approved by /21� Date Y Application Disapproved by: 7 Date for the following reasons r 1 � Permit No. "r Date Issued j ————————————————— —————T / - -————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Construrdt jd( ) Repaired (�) Upgraded ( ) Abandoned( )by tom` i at L(q jk �tSA �C.EJ C1�1'� () l W�,has been construictad in acc dance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer #bedrooms Approved design flower gpd --11l The issuance of this permit shall not be construed as a guarantee that the system l function as de will signed. -- Date /�/ ��'�t i Inspector ----=-----j—I ------------------------- Fee ------- No, /L/ /.��..r <5 too. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS �CX��I c�S+ • Mi5poal *potem Cow5truction Permit Permission is hereby granted to Construct ( ) Repair O Upgrade ( ) Abandon ( ) System located at I-!Q 1"^0 y ' b 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 permit. Date '` Approved by ---� 5 . " THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH V .............OF.............. .l.e Appliratiun -fur Uiiputitti Workii Tonstrurtiun PPrniit Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal � t: / ') ;?Location-Address or Lot Ne. Owner / Address ...... .............. Insta er Address Q Type of Building Size Lot..-__-_---__•_______________Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures --•----------------------------------•---------------- --------•---•--------•------------------------------------------------------------------------ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter---------------- Depth...._--__...... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------- ,� Test Pit No. 1................minutes per inch Depth of "Pest Pit_-______-___-_____ - Depth to ground water-..____._____.____-_---. fq Test Pit No. 2................minutes per inch Depth of Test Pit._______..--_____- Depth to ground water__.__-___-_____-___-.--. --------------------------------- ------------------------------•-----------•---------------------------------------------------- ODescription of Soil '^�`� =p -c1= /-------------------------------------------------------------------------------------------- U ---------------------------------------------------------------------------/---- W V Nature of Repairs or Alterations—Answer when applicable----------------------------------------------_........................_ .................... ------TW --------� l°- °----- c ------ ---- Agreemen : ✓ x The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee_ issued by the board of halth. Signed... C'sL. e'er- . _ Date / Application Approved By------- ------ .... --- ---- ••.E ---°Z IF- ----- a - Y Application.Disapproved for the following reaso .... . -•------------------ Date ... ..................................•.....•-•------------•--••-•---------•-••••-------••-•-•-•-------•..._...-•--••---------.............-•-------•--------........----------------......--•--------.•••-- Date Permit No......................................................... Issued... '. !!' __7. s- Date No......................... FED. ? ?........... THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALTH/ ?...(c�"`� �s�'�._..........O F.....(-��C.L..,. ��C;_- -`f ... ................... Appliratiun -fur 'Mipuiial Works Tonstrnrfiun Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System rat: � ViS 1. ......'-----•-------._.---------------------------------------------------- __: Location.Address or Lot No. --•--------------------- -------------------- Owner Address .....................................-....... ............................................ ...............-----•. -------•-----•-------------------••-•-------•�......--•--------------•-- Installer Address Q Type of Building Size Lot___________________________Sq. feet U Dwelling—No. of Bedrooms______________________________ __ -Expansion Attic ( ) Garbage Grinder ( ) 0`4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) al Other fixtures _______________________________ _ _ Q -----••---•-----•------------------------------•-•-------------------•--•--------- W Design Flow............................................gallons per person per day. Total daily flow-------------------------------------------- WSeptic Tank—Liquid capacity_._.-_-_-__gallons Length................ Width------ Diameter-----........... Depth---------------- x Disposal Trench—No. .................... Width-------------------- Total Length_--___--..----__--_. Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---•--------------........................................................ Date---------------------------------------- Test Pit No. 1-------------___minutes per inch Depth of "Pest Pit-------------------- Depth to ground water_..._---_._--_-._-.----- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-..--.---_--.--___-_-.__ a' ,- -------------------------------------------------------------------------------------------------------•••-------------•------------------------------------- O Description of Soil--------- �._..._........._ / �v_? .._� U --------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- W --- ------------ --------------------------------------------------------------------------------------------------------------------------------------------------- .......................... U Nature of Repairs or Alterations—Answer when applicable--------------------___________________________________________ _ ______________________.. G—z-c� i Ge.i` Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. I / J G 'I G 2 / Signed---: ... ~---c'-�'----v----•� -:._�_ 7 G / -------------- / Date Application Approved By-- !Er=� r E' � �! '� - -----------�-- l�'._ r Date Application Disapproved for tlt.e following reasons: --•-•-••---•----•-•-•-•..............................••-....--•----- -----•-•-•-•----------•••-•--------•--------------------------•--•----------•----•--................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD. OF HEALTH r .............OF_......................... ......................................................... Qrr#if ratr of 01.1,11mlihattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by �,� �..� ----------------------------------------------------------------•-- i Installer has been installed in accordance with the provisions of )ert c�l�e XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.�=--._ _________________ dated..-__2 5"--- .6................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI�L FUNCTION SATISFACTORY. DATE----//--� - ------------------------------------------ Inspector .•---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Cam?- ............................OFF: % /.�Lt..�{% fi` /G. 2.cJ c? No--------------- ------ FEE........................ R-ripuittl ark-4 Cnunitrnrtion Prrmit Permissionis hereby granted----------------------------`-------------...----- - -----------------•--......--------------------------------------•----- to Construct ) or Repair (L-)-ag Individual,Sewage Dispdsal Sy tem Street as shown on the application for Disposal Works Construction Permit No..................... Dated___,. ..... -_____.__.. -s.__ .. . Board DATE.��..z�.. ....0 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LO�C&.T_ION 5E\NO C;E PERMIT UG VILLAGE ` -� - - - - - - — IWSTQLLER S ►JLKAE ADDRESS bUILDER 5 1.! &V AE ADDRESS Dt-\TE PER T 155UED - - D ATE COMPLI W-ACE ISSUED : , f _ J 7-7 i' �— - - RECENTLY REMOVED BY. .:.: � '�' _� _ .-...,. U.S POSTAL SERVICE ._ ..._ '.: ... .. \•'•.` ._:.._._ LOGE OF.F. .28:,.. , - .. '.. IX�D I EE/A APRON ..' -�.. OAD - ROUTE .. .. ET03IfiG SIRI - . FALMOUTH R TO RouIN a.. � REMOVE AND DISPOSE LQAY AND S® .. _ - .-.. REMOVE .. '.IX DRIVEWAY APRON: , .. ., _..:_ E711511/E0 CURB INSTALL NEW CURB .. INSTALL NEW CURB �� _ _ _ -AND LOAM AND SEED YBRIAN Q .. - DO NOT ENTER (MATCH E1aSDN0 ,:: •.'-` - .,. (NA7CT1 EIaSTMC) nl1 ^ .- .. SIRA-(Tw.1 _ +„ TEROATWI - SIGN' nL- _ ;q iL 'rl!�t!V!/',(I .a.,,,-� \ `.•. P.IM Rn/ STRIPED 4I2R f, I ISLAND .. ,..-. r EASTI G[XKc A,:r.. ALE _ YOC SI S YIALI' 1 ♦1 _ ::.................................. ::'.:: :.:':r.::.:.: — eRNN c:'YERGA7W1 DATE: 1 ._:y+r• - .Y ....151 PD1AP7HC.. ..... ........r......: ..... ... A'::::.�.:::.:�::::.. Iit1Y .'ti�_ � ..... .........- ....:1::...........r.....::':.ia.:':::...;:_.:.:'�'.. �.. •::8 'Td.- PROFESSIONAL ENGINEER - \ ,r,\. . .. ....... ... . .. ..... ......... . .....�......L.- -f..... .....,..;....-...r_......... ..1. ..c^ .- ....................... _�. - .....,._ .d..... .. .a..... .. ........I......... .-_....... . ..r...... .LLFF.7t11M (?. ✓'� yd ............. ....sa............ . . •......................... ............_ .............. .................. ................ /:>....f. ... .......................... .. n. ...., 1 _-- .- ...� .. .......... _.. ETL FIRE .. ... :::'................. .\-•.. •. 1 '-�:DFPARTYEAT - -�:r[f'.:::::::.:.'....PARNNG-dVLY.': :...:::...::... -! ..,�., W1-JUI8a,S PAv!11 .. . .. _—.;____—"=.r CONNECTDN. `:gCl. :.. I ,1, ._ --:.:�::r�.�•::'::i}}:^:�.•ii�.`'... (�?rl':•:::•i:•::::ii�:....,....,.'. •_ COMMERCIAL ' •ND•rrn 1..._,. /_,��: ., ,•. I 1 I .' �_. �p ., ... .. .. EXIS RI':.n•I[PHAw - � •.:7.�::::' - 14!?: / REDEVELOPMENT 'UAFt IXU FA'<AG _ L_ - �:.._ .• }.�-..... -, t" t.--_. -- .:... .,+E :.OP.Y NDOO fRAlAE .. ... ,, �':•-�� �' c!RS?F!00.2 ?7.9 : s 'r,+ab!— v.,--_._- -->-y3•/,.+?Y�. ..,_ : •� t._ -:! � .:� ^Ens; r:G.3 o- ,,�i- �• ., � #1495 FALMOUTH RD PROPOSED BUILDING °f," / , .. - - LJ r (. .._'—"-..`. :. , . •, ,'. ,:� ,01:611A r-�.p ON �K. .d' 'ar•.(i' CENTERVILLE J\ IT-. °•N S' (+J,7.n I, d. � .\ �r _ .t'i- .ena-rn�i .. l' .•;r MASSACHUSEdTS , t 7. , -DDMPsiE.R - - Va 1-�_ s.o• :\ /_� _,. �_�\.HFS:P.IuBA>�,DA�SrI./':s /)'nN��-_ _—' I -f-{l.//1y J._Y'��.!I�'.� � ( 7r�P�'r.r T l7 14/ . (BA-RNSTA8 LE COU NTY) 7Y)v � i•1 �INaI'PAVEMENT PROPoft LIMIT OF TREE CLEARING RAT 7..1s, 'IMppU. All .', $IOgAAOE :CFFENCE LAYOUT PLAN .. 1 - '65 YAIMNN E70ST NG./ - I/! ` _ - . ,1, '`I''lt. \\ t -- -Rrr` SIRICTI ,'_-�- WRB-0 BERM, l ARE OF r./ f ^'r%r A.4^.' • .. a7.:a.. — ..4v ..;''y7 CHAL EAT.w �' "'t ♦. I,OAna'� d ♦_ :m.ml. MAY 16.2008 • I•/1 ,\ �~ - '_!' �"sG-I'F �' :-��.- _--•(e //, ��- i. 1. 1. I - :N• RIP,lqlm�- - - - 91,RNcfA0.E ` ELLVATtx,g7./MJ j \`\ r 1` Y NO- DATE DESC. I" t.Jv/ ._ i�. O rt: Ti - i•' :Nlt<l'ROUIIO. \• ., ... �; R ,Iti v'"r.l ( 'a.1H!1 / C., /: /• 1 -0 ET 7-158 STAFF COMMRS .CnHnRF7E n,^,1aU'Frn IHu r•, �.,.,' S1 '�. .f -_\..• , / Q ,` - - 2 8-04-09 PARKING &SITE ENTRANCE . " hlSe!•C'_C �.�. O \I'1�^.�._... i ./�/ DREMOVE C g YWD DI P�A� 'w - �� .. - ♦ /.. _ 3 10-20-09 CONSTRUCTION SET P 4 /' LAb v AND LOAM ANC •F '/} r .-, 1 .• - ' ...- � _ _ �c.` 00 '..cam; •. .n. - j �`� .,;• _.. � .. ,� .. .. r. LEGEND PREPARED FM � - .. REMOVE AND DEMOLISH EMSTING BITUMINOUS' - '�.! . . PAVEMENT AND LOAM AND.SE AREA' , :ANDREA.:PENDERGAST _ ED 1495 FALMOUTH ROAD, RT 28 n. . a - / CENTERVILLE, MA 02632 • , ..AREA TO BE STRIPED WITH WHITE (508) 775-8668.. _ .. THERMOPLASTIC PAINT .. /\.;`� - �/ / l_AY. .• B GROUP NEWCOHCREIE PAVEMENT 92in Ueet Roure 8 Unit W.Yarmouth,Massachusetts 02673: 508 778 8919'. ©saw 8SC aew.V.. SCALE: . a• 20 s P ._.. D 1D zD P40.q.' b.. P:\pri\4930500 - .-. ` Y - .....^ .- JOB: NOc4-9305.00,: SHEET S'.OF 5 _ - ... , i i W4 u A-4 96T Revisions: I R sons. I-A K E DATE DESCRIPTION 10/31/88 CONC. PAD S S -; I2 22/ 88 T/ TREES ADDED E t D D U G R . 1/1 9/89 SID EWALK AT STORE ENTRANC E' M r4 tt s H e 'h 0 5 V E d V 2/23/89 ADD COUNTY LAYOUT e a 4/" 90 ADD R GREASET TRAP,R LEACHING Oc�Tt Z8 I C LO CUS FOR SEP TIC,NOTES O S ` Na - D n O L 1 � s LOCUS P I = f 2083 O S MA References:efe ences. -ASSESSORS MAP 209 LOT8 I - PLAN L N OF LAND N CENTERVILLE A i M AP WATER PROTECTION OVERLAY BELONGING 'TO JOH N J. 8► SYLVIA J. DISTRICT` PENDER A G ST, I1/22/65 , NELSO N BEARSE RICHARD LAW, SURVEYO RS-PLAN BOOK 19 8 PAGE 139 PLAN_ F 0 A PORTION OF ,OLD PO ST T RD. AS ALTERED BY THE COUNTY _ _ _ C O M TEL. Co.. EA E. MISSIO ERSAPPROX(MATE LOCATION 60S0. MASSTEL. & BOOK 257 PAGE 75 T1930 DMH STATE STATEHGHWAY -8 WGR0UTE uRB 987 CB GRANITE.,__ww OWG 9$.9 d UP 99 .23 _ ,a IO2 \ _ CO N C..,... �UR ,�,..99.81 - R GRASS HWS 100 8 0 _ 1 CONC� _ BURB. J0L $ 0TS GRASS _----- - CB - Project Tit le: 102.00 B 98®34 99.02 TS10233 _ --- PROPOSED CUR --- GRASS �. 9.5 4 � 93 , O TS o O TS I00 0 _ 0H 0 104 TS UP 99.79_ ._._- 9 .28 9 GRASS _ 2 5 E 7 6 10 8_e N , _ SIGN 18 UP �. 6 04.61 10 99.5 6` " I04� 3 8 703♦5 L8 5 9 10 3 � TH � :, B _ . E c.__CUR BIKE CON , AP AN ITE V _ RU B N GRANITE OD _ H r SI GN . OO 99 0 4 �. CUR B B 105.6 10 ICE HOUSE SIGN , � fl to , , - 0 B ASET E t0 0.0 6 _ ' I , , B U IL D I N GC0N C. LT 100.03 BUILDING OVERHANG OVERHANG Gs� 5 GRASS 99 i 0 98.88 x / PACKAGE . ._- TO RE LIMIT 0F 14 CONC. z STATE LAYOUT 10 t101o1 STORY o V i x L. BLDG.\ E L T B., E s / AM � / R 0 D F 107. Q 0 Q 9 WO OD �i 99 37 G l)c P IN , T 5�. S u P EXISTING 6{ 9 \ED 0 F 98 ROPO S P 3 . PROPOSED ARE T RU 2 LOT H -; E T o EM D B tea. S 1 t Q B 5 C 5 850 s.f. 5 5 0 7 R - s _ _ W 9 8 H � o L99.29 / X ._ .0 R D P � S A P � P �97 2Cv E P I 4 ) D E `V J / 6 I L A L D` FULL E ; D S H �I t. P B T 0 N E i ._- Q C H _ 4 S D 0/ 0 W 1 P:_-- EX AN o L A R SON 8 L CELLAR D i E )e Q AT -�' _ E L C I E \ ._ E 0 PROPOSED . G � T N o EX ISTING S " o _ _k A , 0 GREASE � .'. ,8 E A S 5 �.D 4 R G_ G�� � W _ 9 } _ Q --g O R : TR AP R P 1 __ c _. D� to 1 ` v ti i08.2 99.06 .I GRASS i 9 G R S 0 GG l i E `. ; RE O , E D H G S 2 E . 0 N P R _ 8 _ GG _ N _ I MP T A 4� D .0 R _• O E E r_ V I V i= _ _ A 0 , D � P E EM 4 R A _. P 5 _ l UI L 9�7 o , 8 OVER \' 0 V G 3 S v Y H Y d P SED U R G _. S PTIC 5 i o 9 5. v N V G o O Q / i 8 T W / / \ PR POSED L 4 _ 0 S 4 ,� �� P 9 cA I - Z p / D BOX n f SEPTIC --�. �k FOR S S _ O .I O v' 0 64 9� _ - s DETAILS, ,S7 9 SYSTEM S . FM 2 0 9 LEVINE � l0 9 �� .61 - 18� HEET F 9 9 - SEE S 0 1 3 4 N B 3 � �. �> cP C LP .. TW IN TREE � o 0u Al 9 NOTES 4 5 _ J 0 W o � , L E'+4 r .i r O P 49 PREPARED F 9. o E E�"' D OR u' i 42 65 9 R�t00 8 P P U o �l c i 0 l \ G la 5 I T ( P L N O PRO ERTY L ES SHOWN HE E P. R N WE_B ) 0 RE P � 0 0 .. COM ILED o �. G � P � T -- � W �� 1 Fi o B DH ? 5 C C / l 0. ,. TS A 0 6 s , B D 10 VE 9.26 � B .�W �.MO ..E _ O FROM A PLAN N RO L N RECORDED A 0 T THE BA - �__- _n RNSTABLE e � 9 _ IN L 2 0 �9 P SJ P E N D G REGISTRYF DEED A CHIN0 S PLAN BOOK 198 ..PAGE 139 E R GA , PROP LF1\ \S �' 1 98 4S T .*7 i _ 99 I � s I .4 CH NG R 00 i � AND DOES "NOT REPRESENT A / S T N ACTUAL SURVEY ON PIT �I . CU RB _ P 0 S ED oT P RTR UST T TH E E GROUND.T P R _ 10 I , C COUNTY A N � TAKING CO NG 7 . . 65 4 4 � Q C 4 \ ,CON 00 l B A S E 9 8.6 L T , 1972 2 1 B ELEVATIONS BA ED A o R TIONS S ON N ASSUMED A „ `.� cu 98.96 , ) SS DATUM. 108.2 16 : ' , II 0 E D 1 _ A l T I E )� R _ ( T B � 8 : 7 4 Ei ION OF UNDERGROUND� 3 L A U L TIE I A ASS OC T T S S APPROXIMATE GRASS 9 ) 5 O 0 u I 0 2 '� 5 AN D ND SHOULD VERIFIED (N THE FIELD F� 0 0 ELD BEFORE „ R �1 4 10 � 0 I \ _ 4 N TS CO NSTRUCTION. . - . ,y5 _: 102 8 £? 1 0 0 o 9923 0 4 XI i P E SING L. PITS 1 234.&5 T E 1 a ) 0 B REMOVED -AND ND BACKFILLED 0 7 II 6 7 r s T F F EXISTING W H Of' HAL 0 „ _ � WITH CLEAN SAND. GREASE TRAP TO T 11 _. l o0 4 RO PL � G P O I 9 9 D -C Y H E BE REMOVED A 6 R MO ED AND FILLED WITH AND. EXISTING G 0 S N LINE INTO E CJ 2: B AS N 0 1 I � E 0 ) i F 0 ,I 98. GREASE A 108 3 Q S TRAP TO BE PLUGGED. I� , 5 107.8 4 Q I O _ a 0,V A.M. Wilson on Assocl 5 00.4 4 , 0 otes 5 i �I In c. 97.$ :.. a . � 99 0 0 104 , 2 . 6 3 5 106.8 0 0 N 97 100.28 �... E t t� E J 1 I r I 9 1 Main Street P 0ste i _r F rnll e MA 02655 6 0 61 - 2 -14 O E 7 4 8 50 O G EP ADDRESS: FAL MOUTH ROAD o r - Drawing m9 Title:6. OWNER SJ PENDE GAST TRUST 106 CATCH BASIN CB QUESTIONS REGARDING THI S PLAN MANHOLE MHo SHOULD BE DIRECTED T0 GRADING UTILITY POLE UP AN• .. DA.M. WILSON ASSOCIATES INCtRAFF C SIGN/SIGNAL TS0 911 MAIN STREETCONCRETE BOUND/DRILL HOLE CB/DH EXISTING ELEVATION 98.75 O STERVILLE MA 026 55 GUARD POST UTILITY . f508� 428-1450 HYDRANT HYD I R _ I0 -EXISTING CONTOU S R -0 ., PLAN EXISTING LEACHING PIT LP ZONING ELECTRIC LINE UNDERGROUND E- E E s> t4 O SF M L s� HB 'QS A A SEWER S S SA NITARY RY SE S E • If � 9 i z c STORM DRAINS D D D ARE A 40 000 s.f. � 9t T y EDGE OF EXIST PAVEMENT FRONTAGE 20 F Q i a� D LJR yl ELEVATION (100.00) l60 PROPOSEDWIDTH : "V 7 100 � 22341 2 9 , . ,. PROPOSED CONTOUR SETBACKS _ w D TE L PROPERTY LINE A FRONT YARD 60 F . � � s G E S, E� M . EXIST V SIDE YARD 304 ONFi E / PAVE. EDGE '"�•,. r_ p .., � PROPOSED PAVE. EDGE REAR YARD 20 2 S 8 o a! HEIGHT 30 1 I � fr EXISTING DECIDUOUS TREE - EXISTING CONIFEROUS TREE LOT COVERAGE Scale. 1 = 20 /o (BUILDING) 30 - 0 FEET x SEE ZONING SREGULATIONS R 0 S Date. 10/19/88 Dw9 No. _t. Design: MJ D Check: , RFD Drawn: MJD _ Job No. 2.0351.0 Sheet Iof 4 7 v l U d W E N s 4 A Revi i L ons. DATE DESCRIPT ION N 1/19/8 I 9 SIDEWALK A� T 5T ORE ENT RANCE E C RE n r �, A�s NOTES ES � FA R KING CAL. . TABLE. .y y N I N 3 e 2 J23/89 AD D COUNTY t r4 a e LOCUS / 89 4 20 / AD D D POSTSFENCE ENC E G .. R .,f 6 REV .' PLANTER NTE o s t R P } PON G O 0 L Q v I J t L*0 US C MAP A I 20 f 8 3 References: s n , re ces. P LAN OF LAND l T O NG E E N R V E M LL A BELONGING D D TO JONN J. a S Y V L 1 A J. P N E R ST DE D II /A 2 6 2 5 NELSON B RS EA RI CHARD R GN D LAW A A RV Y E L r SURVEYORS-PLAN 0 9E?-BOOK P AE D /39 PLAN OF s A POR TION TI 0 N OF OLD PO ST�T U. AS ALTERED E R E t� R D Y T f HE COUNTY 0 N TY _. C 0 M UT 930 MISS 0 RS BOOK 2S7PAGET5STATELAY0 ROUTE 2 8sTATEHIGHWAY PROPOSED I I I P GR ASS A S S STR d _ <== IIiIIIIIIIIiIIIIi ,,F,I.3II,II►fI,iIa. ta.IE,rIfixt,, , . . . : E _0 G :. 0 F P pV 3E` W A Y 1 0P L P 0N T E PPE�-o _P2 0 G E P P2v 4 P G 0v L _ A 8 19�r •,, G R A S , _ , , - rr. P E w f P OG S J T SPRoPOSED O " a- �oU� - ; 'r r Q P � . ._.._ - . _ . s r _ _ P r o J e ac G t CT � �iL t' D iIleOrR r .• GRASS PROPOSED o O POSTS ND SPL1TRAILFENCEA B KEPATH PROPOSED GRASS.. A Y y 2 L 9 �P rJ _ Z .1�n' S <E . /) �a } CODPLANTER 3 GRASS 0NE OF STATE LAYOUT PACrrAGE to M REGONS T Q O C LIMIT 3 ME BUILDINGWO0DFRA GRASS ' PROPOSED. 5 HED J EXPANSION' SHED as � GRA 3 GRASS 4 EDGE OF PAVE PREPARED FOR: SJ ENDERG ST COUNTYTAKING TRUST 1972 0 5 GR 0 DF A.M. Wilson Associates OF Inc. AavE ' NOTES: SPERSIfE PLAM REVIEW 9t1 Main Street Oster Ile MA 02655 617_4 8-t450 Drawing Title: PARKING • PLAN PARKING CALCULATIONS AREA PARKING : AREA PARKING USIE EXISTING REQUIRED PROPOSED REQUIRED F. OFFICE 913.5 S.F. 5 3 24.0S.F. 12 . REf L 3805.6 S F 20 4719.i S.F. 24.5 Scale: 1 _ 20 STORAGE 0.0 S.F.S.F 4.5 3190.0S.F. 4.5lNA o FEET Dater I07l Dw9 No.9/88 Design: MJD JARTOTAL 30 41 Check: RFD " , .. ... ,r ._ - r D wn JA R R N . Job o. f 5l h 2. 3 o 0 0 Sheet 2` 4 , I _ MANHO4 Ir COPM TO F11i GRADE NO, OF OUTLETS.-_5 HEAVY DUTY MANHOLE COVER TO GRAP�� PROPOSED GRADE Revisk": SOIL TEST PIT DATA: 20'" NOTES. INDICATES 10, t2*MIN. 1. DISTRIBUTION BOY TO WITHSTAND M-10 2 LAYER OF 10/31/88. CONC. PA PZRC INDICA77-S OxSLrxVZD COVER r-6 LOADING UNLESS UNDER PAVEHEN`7� DAIYES PEASTONE, IV30/90 DESIGN FLOW EACH rzir GROUNDWArEx OR TRAYELED WAYS WHEREBY H-2o LOADING IL ING, 0�. If .. r -1 SHALL APPLY. 7 ADb GREASE TRAP If 12 1 IN LE T, 2.PROVIDE INLET TEE AS SHOWN WHERE pe, TP No. TF, NO. 9 IIE TEE I SLOPE OF INLET PIPE EXCEEDS 0.08 FTIFT _.!M�Pj OR IN A PUA!fPED SYSTEAC H-20 I Ile GRD.Er_ 102 GRD-EL 3 PftCAST,STEZL 61 L J.FIRST TWO FEET OF PIPE OUT OF THE GW.Er_ GW-Er_ REmFOIi % 5-1 PLAN VIEW DISTRIBUTION BOY TO BE LAID LEYEL_ WASHED SEPTIC TANK 5 iii INLET OUTLET-f �-i 11 if 0- 0- 4-9" : NK TEE 11 6-1 4. RECOMAfENDED MANUFACTURER - STONE TOP SUBSOIL AND TEE LIQUID DEPTH- ROTONDO OR APPROVED EQUAL. .51 -101.5 GREASE TRAP SEE NOT9jj emm 2 REMOVABLE COM MEDIUM W TO HA"STONE 3 vI 2 1/2 2- COARSE 2 - fi'.i fIr eL'k '0i-, F 50 DIA.OUTLET(S) SAND BOTTOM ON LEVEL STABLE BASE e L 61, 7-L'i - .I.' :.. 0 tDE 3- 3- 240 OW MANHOLE COVER 0 -jii fi t.IL" rAft-75;_07 WATERTIGHT Pii JMTS (TV.) 4 4"1 LET 6' DIA. 4- 4- PLAN VIEW CROSS SECTION VIEW 4*OUTLET-1 Refererces: I& If 14' D I A. 6- 5- x0i 4 Lim I SEE SHEET I OF 4 6 1.SEPTIC TANK 7V WITHSTAND S-10 LOADING 3. OUTLET TEE'IN GREASE TRAP TO BE WITHIN INLET 6- UNLESS UNDER PAVEA(ENT. DRIVES ON TRAVELED if BOTTOM ON WAYS. WHERE BY M-20 LOADING SHALL APPLY. 12" OPI BOTTOM OF TANK. 2 LEVELSTABLIE X,%. BASE 7- 7- 1 ALL PIPE CONNECTIONS AND CONCRETE COi 4. RECOAfWNDZD MANUFAC717MA ROTONDO OR emmIK3AUTO H- 20 S7RUCTION TO RE WATERTIGHT. A"Ai EQUAL. CROSS SECTION VIEW 111--BOTTOM OF H-20, W20 STONE LEACHING PIT DETAIL HOLE SEPTIC ,TANK & GREASE TRAP DETAIL NO. OF GALLONS.' 1500 DISTRIBUTION BOX DETAIL 9- NO WATER .9- NOT TO SCALE LOCUS MAP no, NOT M SCALE SCALE 1'-201 10- ENCOUNTERED 10- SYSTEM LAYOUT DESIGN ANALYSIS 1 =20' 12. 12- ------i DESIGN FLOW. P 7027 OFFICE 44 52 sf X 75 GPD/1000 sf= 334 GPD JDA73L, 8/16/88 bA7X- RETAIL 33 50 s f X '5 GPD/100 sf= 168 GPD, EXISTING STORAGE 3647 Sf X 5 GPD/100 sf= 182 GPD 7ZSr Sr.* 'Imss ST.- M J DONOVAN BUILDING S L A 8 TOTAL 684 GPD Flivood Title, Wff WSJ= wffwm. G, DUNNING SEP77C TANK REQUIREMENTS.- H-2 0 TANK FULL GPD X 150 % = 1026 S GAL PEXC-XATX* PgJtC-* XAYX- CELLAR USE 1500 GAL. TANK �.'.PROPOSED -DISTRIBUTtON BOX V WMANHOLE COVER TO FINISH -GRADE PROP 1500 GAL. 4" PVC V\N- 77 N& 77 No. GREASE-TRAP S \1kxG CAPE COD GXDXL GRD-EL. �5 PROP 1500 GAL G.T. GWXL GW.EL SEPTIC TAN (L P 5 PAVIE D 0 - OVER LEACHING FACILITY REQUIREMENTS: GPD PROP 4 PVC PIPE , S.T SCH. 40 (TYP) APPROX. ENQ, OF NOTE:LOCATION OF UNDERGROUND PACKAGEL STORE If EXISTING 6 PIPE �PROP 6 DIIA.iii DEEP ®r�% UTILITIES IS APPROXIMATE 2-a�DEEP-6" DIA. PITS W/4 TONE 'ELEV. = 95.91" 2 - �ILEACHING PIT ONLY CONNECT EXISTING,SEPTIC .-W/4 STONE LINE WITH NEW TANK SIDEWALL AREA 154 SF/PIT (2)2.5 769 GPD So 3- 3- TTOM AREA 154 SF/PIT(2)1.0 308GPD 4- 4 - PIROPOSED Or TOTAL 107t GPD PROFILE S_ S_ SYSTEM NTS 6- 6 - NID ell MANHOLE AND COVER BROUGHT MA FINISH GRADE F TONE_ 0 2 DEEP, 6'DIA. LEACHING- PITS-WI 7- '90 TO FINISHED GRADE EXF_/-%NSION 7 _01 VO LEACHING FACILITY PROVIDED: H-2 0 PITS TIE IN To FIRST TWO FEET TO PROVIDED 1077 GPD EXIS CAPACITY 9- 9- 'TING BE LAID LEVEL E �_4 2"LAYER OF PEASTON ItAPACITY REQUIRED 684 GPD iR 10- 10- \95-65 95.51 - 95.9 95.34 T 95.14 1500 GAL. 3.5' 3/�' WASH ED STONE H - 20 DISTRIBUTION Box � SEPTIC TANK 12 12: TO BE INSTALLED ON A j NOTES DArJL* DATX- 7 7 7 7 7 7 7 7 7 7 1 LEVEL, STABLE BASE B TOM EL.= 91.64 PREPARED FOR: I UNLESS OTHERWISE NOTED, ALL CONSTRUC- LEACHING PIT TION METHODS AND MATERIALS SHALL Cii jZS2 27. 21SI 8T. FORM TO TITLE V OF THE STATE ENVIAON- S i PENDERGAST MENTAL CODE AND ANY APPLICABLE LOCAL W"J="ff.- RULES AND REGULATIONS. TRUST 2 GROUT TO HE USED AT ALL POINTS WHERE rzxc_SAM. PERr-"rr-- PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES IN ORDER TO PROVIDE A WATER- TIGHT SEAL 3 ALL SHIPLAP JOINTS IN SEPTIC TANK SHALL STANDARD DETAILS rTS BE SEALED WITH NEOPRENE CASKL ON SCALE AS N OTED ASPHALT CEMENT TO PROVIDE A WATERTIGHT SEAL INVERT ELEVATIONS 4 PRECAST CONCRETE SEPTIC TANK, DISTRIBU- 4' INVERT AT BUILDING N/A TION BOX. AND LEACHING FACILITY TO WITH T96, STAND H-10 LOADING UNLESS UNDER PAVE- MENT, DRIVES OR TRAVELLED WAYS WHEREIN INVERT AT SEPTIC TANK (in) 959*(EXIST) A.M. -Wilson HEAVY DUTY MANHOLE COVER H-20 LOADING SHALL APPLY. TO GRADE. Associates 40INVERT AT SEPTIC TANK (out) 95.65 5 ALL PIPES IN THE SYSTEM SHALL BE SCHED Inc. 4' INVERT AT DIST. BOX (in) 95.51 ULE 40 OR EQUAL 24"DIA. PROPOSED GRADE 4" INVERT AT DIST. BOX(out) 95.34 6 WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT. DUST AND FINES. 37 911 li Street 7 AT ALL POINTS OF INTERSECTION OF WATER Ost"Ie/lfi 02655 INVERT$ AT LEACHING FACILITY.' PRECAST CONC.DRYWELL LINES AND SEWEA LINES. BOTH PIPES SHALL 617-428-1450 (H-20 CONSTRUCTION) BE CONSTRUCTED OF CLASS 150 PRESSURE 4' INVERTAT BEGINNING OF PEASTONE FILTER PIPE AND ARE TO BE PRESSURE TESTED TO LEACHING FACILITY 95.14 -.10" Cmp ASSURE WATERTIGHTNESS. Drawring Title: 0 4r INVERT AT END OF 8 SEPTIC TANK , DISTRIBUTION BOX, ETTIC. TM LEACHING FACILITY N/A C t= 10" CMP TO SHALL BE MANUFACTURED BY ROTTJND0 OR AN EQUIVALENT MANUFACTURER. Mp ELEVATION AT BOTTOM OF 6 LEACHING 2'OF 12"C PIT C3 LEACHING FACILITY 91.64 C_E M E N T SUBSURFACE _C ENT MORTAR J__� i 9 EXCAVATE ALL UNSUITABLE MATERIAL IN 3 _:--_ ? LEACHING AREA AND BACKFILL WITH CLEAN C3 CONTINUOUS WELD AT JOINT OBSERVED GROUND WATER 2 1 V2 DIA. HOLES GRAVEL OR COARSE SAND., 7 cm C3 cl m SEWAGE ELEVATION N/A 10 HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE 10"Cmp 6 - I . . . . . . .. . SEWAGE DISPOSAL SYSTEMS DURING THE W le I t__1IliSfI1__lIi COURSE OF CONSTRUCTION OF THE SYSTEMS. DISPOSAL DESIGN NOTE:EXISTING LP3 SUMP ELEV=89.0t . 6" 81 DIA. 11 NO FIELD MODIFICATIONS TO THE SEWAGE 4" INVERT AT GREASE TRAPON) 96.11 DISPOSAL SYSTEM SHALL BE MADE WITHOUT AND 4' INVER I I CRUSHED STONE PRIOR WRITTEN APPROVAL OF-THE ENGINEER TAT GREASE TRA j�k OF to P (OUT) 95-94 SLOPE AS INDfCATED AND THE LOCAL BOARD OF HEALTH. ON SITE PLAN STANDARD DETAILS DRAINAGE LEACHING , PIT DETAU ROBERT 12 THIS SYSTEM SHALL BE INSPECTED--AS RE- I" TOP COURSE F.- QUIRED BY SECTION 2.10 OF.TITLE V. NOT TO SCALE i" DAYLOR 2' SINDER COURSE No 237 41 1 13 A CERTIFICATE OF COMPLIANCE AS AE- '0 0 T Sq'i QUIRED BY SECTION 22 OF TITLE V MUST BE 00� 001 e 6" GRANULAR BASE PC "415 he., . -%C, "'o Z, 110 � AL OBTAINED BY THE CONTRACTOR UPON COM- 11� fit PLETION OF THE ABOVE WORK. -IF AN OAS oc"i 45 % - PLAN IS REQUIRED DUE TO CONTRAC- COMPACTED SUBGRADE:�;;'/` %%-- , /,i BUIL7 CATCH BASIN TRAP DETAIL (SUITABLE SOIL MATERIAL) \0 TOR DEVIATING FROM THESE PLANS. WORK Si low AS NOTED FOR SUCH OAS BUILT' PLANS SHALL BE NOT TO SCALE COMPENSATED BY THE CONTRACTOR. 0 FEET 14 THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL UNIT. Date: 10/21/88 D*g No: TYPICAL PAVEMENT DETAIL ''NOT TO SCALE 15 ALL ELEVATIONS ARE BASED ON ASSUMED Design: MJD DATUM. I Iv T, Ll FC4-:I N�L C T ro G T e35' OT _CTI�141�. T ROBERT Check: R FD Drrwn: M J D Sheet 3 of 4 t Job No: 2.0351.0 I - - -----7--'------*--�-L�,�?---!�1-----'-�-,7��,_-,-I_ 't�,,.-'""-,1, " 011, - , _'. _�, __ _1 _______ ,_,--_-�C-�-.�7-1,,�,�S.__,.�,�,-�-,:- _._.O_��,_ 1�-...'-,-�-� >�";-_- =7---,-�-1--,�r'',�� � ��,_ , , ______ - - - -"--- - _--.-_.--_--__ - , , -_ 0-7z"-, ,,,,,,� - I --------. - - , �:� I I "'" I ��, lv� �- - - I __ . - - I I � �. .1 11� I � I �--1111-,� � . _-11.11 -."-! ,�', , _�� - 1- I 11 .- I � I . . �' � i .11-11, I I I I - 11 I� 111.1 I - 111. -� ", 11q1111-1�1,- �I_ -�,--- , _"'M �- -,-�, -_ , � --"''w 1, ,. � '. 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I � I I , * WEQUI�,QPIFT , Revisions: � I , I I �_, - �, I I I ". - - . . I . I . . I I I I 1 I 11 11 *_ I . I , I I I I . .� I , I 11 I I I I I I � 11 I . . , I � . I � I ," - ' 'I i I �, :� ,- � I � I . I I I I , . I . . I . 1, I . I � I _,1 � 11 I � , I I I � . . . . I I I � /V / I � , � I I I I 71-- I I I � � �, , I . � I I � I - I I . I . I iI:11",,,-,z I I I I I �Il I I 1 . I I I � � ,� � I: I � . � I I � I I " ' I __1, I I I - I � I � � I I� � I I � I � I I 1. "I I , , I I "" �N Y,F_ - DATE . DESCR I I . I� I, i I . .1 . - . , � � I I � 1. - , � i I I I . - � . I . I � � I I I . I . .1 I I I _� I I �� . I - I I � I I I � I 1� I . I I . I I . I I I � I I . IPTION � , I . I I I I .1"', I I I I I �,", ,"��,� , �, , , ',,� , ''.:. , i I I I I , I I ', I " - I ,I � � . I I // - I - I I � � � I " . � I I � I . I I I I I �, - I , I I I I I � . I I , , I I I . . I 1. I iC , , ��. I : , - I . .1 , I I I I . I I I I . , I I I I I I I I I I I 11 , - '. , I , � I I I I . � I � , I � I I I I I .. 0 1 - � , , c I I I � I I I - " I I � � � t I, I I I I - . . . . /'-) , I � 2/23/89 ADD COUNTY L,O, , 1, � . I I I I � ,�I I . 1. I _� I -1 . � I I I I . - .�_ I �, � 1. 1. I I ,� I . � I . � I I I I I. . I . I I I I I . I I 1, ,� . I 11 I � . I , 1� 11 11 I � I � I I . I 1\�*' . I . , '' I I,t, 1. - � I ,- , I , � I �- I I I .. I � . I . � � � � � , . I I . ?-/" , I I " I I I � .I I I I I � _ I . . i � I I I - I , � � . I I I I I I � ,.I , I. I . I � I - t � � I I I I � � , i I - � I I I I I I I . - II I I I I I " ,, " . 11 . � . I I � I I I I I � I I 1 I I I I I � � I I . I I I " I '. I , . I I � �, � � I I � I . I , � , � � 1, r I I � . I I I I I �,�, � ", I I, �. .� .1 � I I I I I I I I I � I I I I, � I I I I I . " I I I C.ReA'r \_�I I I � - I - . � � , � I �,,,� , , , , I _ I I I - I _� I I I I I . � � I I I I I I 11 AR 114 I I I I . I �, , , � . I � .I I t�- I � I � . I . . 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I I I � � . � I � I I I - .� , I � - I - � I I . I � I . " . I . I . I I I I . I � I I I I I I I .� I I I I I I. I , 11/22/650 � .1 �, I I ,� I i , :'11 7 � , �- .1 I - I I � I I . I � � -1 I � I I I I . � - 1 I I � I� �I I � � I I 1 . . I 1. I I I � I I � - � I - �� - 11 I . NELSON BEARSE-RIC14ARD LAW1 I 11 I. I 11 11 - I I I I . � I : . I I I I I I 1. I I � I I 11 I , � I I I .� tl .''I ' 11 I I � I I I I �I I I . - I I -I � I I I � I I I � � - I I � I I - I � 1 I . I I � I I I "I � I I I 'll I I I I I � I I -PLAN BOOK 196 1 : 1_ 1� I I�� I � . . I 1 2 � � I I SURVEYORS - 1 II I I I � - I I I I I I � I I I I I I � I I I 11 I - . I I I I I I � 11 I - .1 I I I . I - . � 11 I I � I . 11 PAGE 1319 I � I � I I 1. I I I I I , : I .� I I � I �, �, I " I I I I I . I . I � I , . . I I I I I . 1, I "I I ,- I I - I I L . I 11 � I I e�, , I V, I I I L 11 I I I � . I . I I I , I , I I ,� _ I - . I I Z, I I� I I I � , I .I ,�, "", -1 - I 4 1 , 1� I 11 - I �. I I � I I I I � I I I . 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I I 'll , . - I - � � I .1 � � I I � . ; � , I_ *1. � . I � 1_________ I . I � I I I .- . I I I I I - I I I 11 � I I . I � I . I I I I I - � I 1.� ,� � - .1 � I., 1 . � I I I I I-.-,----- I � I � � I I I I I I- - STATE LAYOUT 1930 I ,- I I I I I I I I I I . . I I I I I I � I � . I I I 11 . I I . ! I � � I � . � � I I - I I � I � I I DMH1 I I I I I I 11 .1 I I I � � I I I I I � I � � I I I . I � I I . I I I I I , I � - I I "I I I I 11 I I . L I I _______�_ , - TATE HIGHWAY � � � I 11 � I I . . � � I I I I � I I �._ : . � I - _____ UTE 28 - -3 � . I , I I 0 1 - I %. 11 I , I . � I I I I � RO , ,� . I � � I 'k I I I � � I I I I . 11 I 4 k 11 . � , I 11.1 � '' I - ��. '' I I 1, I I I I - 1 I I .1 � I I I I I I I I I I I � I I I 1 I "I I I I I - I 11 I -I I I I I I I I � WG � I I , I .1 , . . � 11 I I I I I I � I I I I I "I 41 � �1, -: . I I .1 I CURB 98-71 1 1 i 0 . I . . � - ,� , I I _. I- I (I , : , I I I . I � � I � I I . - I � I I CB GRANITE I I 11 I � � I I � L � I I I �_ I I I I � I I I I I I I I I I I I . � , � I OWG I I . I ,� I � I I . . � �, . I � 1, I � - I � 98-91 1 . I I I I I I I � I . I I � �, I I, - I �, I I 11 1 � - 102 -,, .. - I . I I I I I I . 11 I I 0 � I . .,99.23. _._ . . .. 1, I 9BEB44 � I - .---- I . I I � I I 1� I ,( 1. � I I � , I' ll .1 I � � � I � I I 11 I I.1 I. . I I � ___��___1O0.86_- �., I - I I I 11 11 I I - ,CONC_.CURB -1-99.81 -1. . � 1. . I . I I � I UP I - - I � I I I I I � .I I � � � � I I . . I . �, I - '' . I I 11 � .1 - ____1 , I I 11 I I CONC CURB_ 10 -18-., , . I -,_ 100.31 1 .. I - I I� I � I I I OHW , _ I - _� - ___;1 I I I . . I . I � � I I I I I I -�, I I I i 11 I I I I , I 10 -'-- I . 102�00 , ' � I .4___ __ ___j=___�_____ -_ 1. . Ii. "', I 0 TS . . I � _�_ - I - 11 . - I I . I I I I . I I � . I I I � I ____ ______ , I "� , , - 2,'33 �,777 _� I- I I I I I . � I I I . I . I , � I - - I GRASS , I - - � I - � . 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I � 11 I 11 I I � I I I- I , I I , � 10037 1 1 It 1 , I - I I � PREPARED FOR: � � - �.' 1 , I I . I . I � � �<\ , 109.26 1 1 1 1 1 ____ , I " - � UP I � ,� 11 I I _ . I , , I ,'I c� I 11 I 11 I I I , I -1 I I - I I I � I 1, I � t \ I:) ' 11 I I , � 11 I 11 1 I I I �, S ,bW(3 1 . - I 1. I , � - I . 11 - . ,� I I , \ I . 1 \ \\ ,. , I I I 1, � I . � � 1,. I CB/DH - I 1, )PROPERTY LINES SHOWN HEREON I WERE ,COMPILED - ' � - � I � � I I � : , ,,� , : �', . i " I I I I I � �� , J , 1 3.� �A ,� , � I �, � I ' � I ; . �. I ,� � ' 11 I '. I � � I I I I �11 � '. ,�'. . _.,tn� I � , I I I I I ,� I �I � ,�Y,�"'' � _. I 11 I I I I I I I I I . 1 ,I � I . I, . I I . I I � . � f _�_ m -, I 1� � 11 I I I I I I __ > sl � I . I 'll � I . ' . I 11 � I ' ' I 11 I I . I � I �, I � I 1�4 � - I /. � I . I I I � I , ,� - . I � . �( � � I I ,, I I , ;� OT � I I I c I I �: I � � 11 - , 1z � � ,�, ��.'A_', � ,,, - r . I FROM A PLAN RECORDED AT THE BARNSTABLE I 11 I 11 11 11 � - , I " 1, 11 �� I . I . I 1� 1. 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I I � I I I I , I I I - I I I I 11 - - . 1067 1 1 CURB :.�, . I I � I - I . 11 . I i I 1. 98.61 ,, 1 ' I I � I . I �,11 , I I I I I I � �, I ; I . I I . � � .� I � I : I I - � I 11. 1 "I . � 11 I ,., I I � .11, - I �, .1 . \ --, :" I ,a I � t I I [ , ,,1��' " � I- ' ' ,�� I I . ; . : �� 1. � . �. I � I : I.1, " 11 , I I I � I � . 1 I I \CJA , I � � I �, I " - 8.96, . . I I � ,� ". I " : I 1 12) ELEVATIONS BASED ON AN SSU I I I I . I I " I I T �11 I 'll� . I I 11, I� - 11,- I . 1 � I �, � I 1 I . I . I I � I I � I \ � "ASS --- I I I I I - I I I I I " I , , , 7 I I, 11 I � � - , .1 . 1-1 I I � � I I . I I . � �� . - I I : I I I . 11 � I 'll I , 1: ,; V, , , , - � �� I - I I - I I I I I 11 / , I - � I I 11 & 11 I � 1. - � � � I I � -I I r,1. � I I I I I 11, I I � I � I ' I - I - I ": � I I " I " I 1� . � , - I I I I I I � 11 I I ,� . I I i - � I I I I - , I . �; I � I - � I 1, , � , I , 11 I 0I I . 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