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LATINOS MINI MARKET - RETAIL FOOD
LATINOS MINIMARKET 115 Corporation St. Hyannis II b ORMERLY SALVADORIAN CONVENIENCE TOWN OF BARNSTABLE LOCATION I I CQ s`P*-)r'O+, w n I-A SEWAGE # VILLAGE Ilan n I--J ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPVC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 0 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet ^ Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet'- Furnished by P��� ��� ® � :� u� �" - 1 � , � � � ���� �r`Lew oUxlcrg Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. i UARNSTAULL F.P.(Thomas)Lee seq. 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D.,Alt. Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 76 Issue Date: 01/01/2022 DBA: LATINOS MINI MARKET OWNER: LATINOS MINI MARKET INC. Location of Establishment: 115 CORPORATION STREET HYANNIS MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IncloorSeating: 0 OutcloorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2 O2 2 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I SF l fecvl C�co,o� oF1HE For Office Use rqy Only: Initials: Town of Barnstable ZF?z�—Amt Pd$ (�Date Paid BMWSPABLE. : Inspectional Services MASS. .ash Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT 'DATE v� o 022 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: Lc-t�;n©s �r��T Nl�re, i�tOL . ADDRESS OF FOOD ESTABLISHMENT: 1 96' CprOL3rat arl b 1 col v� MAILING ADDRESS(IF DIFFERENT FROM ABOVE e- lS( E-MAIL ADDRESS: 1rMG«�yUi�ur4�S��C�y►1c1; �� TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (5 ) 53 - 9121_ TOTAL NUMBER OF BATHROOMS: 12' WELL WATER: YES NO / ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** 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 qw- OWNER INFORMATION: �7 FULL NAME OF APPLICANT J-T rr ju u►Ian O^q. co V` SOLE OWNER: YES "NO OWNER PHONE# ADDRESS C\' rl vt .e ILIA 6 CORPORATE OWNER: -F—t- Cat I tt+ I VAC W1C0 E�,+Ti Ws to-Aak6T Flo QC MC CORPORATE ADDRESS: m- COrpO►''a-�.On 02(od I v 3 A PERSON IN CHARGE OF DAILY OPERATIONS: Ty-y`lc� ' Ut[cli- U-'+CA h_CJ ' 1 . List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. 2. t SIGNAT RE 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 I st to Dec.3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. QA1Application FormsTOODAPP REV3-2019.doc Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 �. Regulatory Services Department Public Health Division MAQ9• Thomas A.McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt ';Food Service Permits Payment received: $200.00 (Cash) on 2/7/2022 Permit number: 76 Business: LATINOS MINI MARKET Owner: MATTHEW H &LATINOS MINI MARKET INC. Address: 115 CORPORATION STREET, Hyannis E :Note: ANNUAL FOOD PERMIT 2022 - FY22 w/NEW FEE i i 7 dFIW. Town of Barnstable BOARD OF HEALTH John T. Norman Board of Health Donald A.Gaudagnoli,M.D. BARNNST.ABLE.: F.P.(Thomas)Lee,. MAS& Daniel Luczkow,M.D. Alt. 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: 76 Issue Date: 01/01/2022 DBA: LATINOS MINI MARKET OWNER: LATINOS MINI MARKET INC. Location of Establishment: 115 CORPORATION STREET HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: G�� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE i Restrictions: For Office-Use Only_ Initials. Town of Barnstable p �$ ' Inspectional Services : .�artsreu. � ' ,�,•KAM Public Health Division Thomas McKean,Director 3 paij 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 50&790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 3 -Z 1 NEW,OWNERSHIP- RENEWAL r l NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT. 1 5 COC 6 rd• i0 n y a,yk.A 1 S Z6 OJ ,Ue� MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAH:ADDRESS: eF Or, Z,C,U..z�-u r- T TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (5 09 q _ 9 12 TOTAL NUMBER'OF BATHROOMS: �- WELL WATER:YES NO V/ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUALS SEASONAL. DATES OF OPERATION: /J�_ TO- NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN-A COMMON VICTUAL-LER'S LICENSE FROM LICENSING DIY. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING I 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 foals(foods requiring refrigeration/freezer) BED"&-BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential ldtchen) 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 508-862-46" Q:Woliekioii ForinstFOODAPP-2020:dbc ti OWNER INFORMATION: r FULL NAME OF APPLICANT. Lo y O NZ:0.AR-7- SOLE OWNER: YES/NO D.O.B `3- 12-I LkOWNER PHONE It O a S O S— `� �•Z �/ _ ` �r� C a IADDRESs C VS CORPORATE OWNER: Q-O-c L.&S G©'(\ZJ0.Ue -L CORPORATE ADDRESS: t ��i'Cl 6 �� j A Kk l SCE Z(o 8 f PERSON IN CHARGE OF DAILY OPERATIONS• 'mac l-6 �p nZst-�Z List(2)Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div.will NOT use past years' records.You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. 2-. 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 508-8624644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State'Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asa. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January Ist to Dec.3I"each calendar year. IT IS YOUR RESPONSIBILITY TO.°RETURN THE COMPI ETED APPLICATIONS)AND-REQUIRED FEES BY DEC Ist. QAAppGcaLion FoimsTWDAPP REV3-2019.doc I Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. aessaaate = Paul J.Canniff,D.M.D. MA ft.. 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, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 76 Issue Date: 01/01/2021 DBA: LATINOS MINI MARKET OWNER: LATINOS MINI MARKET INC. Location of Establishment: 115 CORPORATION STREET HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office Use Only: Initials: Town of Barnstable , Dade Paid � AmE ljdl�d$ +8Inspectional Services - _ -__� Public Health Division =_� Thom-as McKean,Director 200 Main Street, .Hyannis;MA 02601 Office; 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL A NAME OF FOOD ESTABLISHMENT; 1 f C� . ADDRESS OF FOOD ESTABLISHMENT:. U K j 0 V-a-kk ti n �kN, ©Z6 01 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDREss: a�n�1�z�i.br�d� ®u4 tOotC , cdm TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: _ WELL WATER-YES NO V ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:�!_/c TO ( f NUMBER OF SEATS; INSIDE: OUTSIDE; TOTAL,- SEATING, MUST OB`I`AIN A COMMON VICTU_ALLER'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($)? 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 INSPECT_ION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508462A644 QAApplication FQms\FOODAPP 2020.doe 6WNER INFORMATION: FULL NAME OF APPLICANT JZ_ SOLE OWNER' YES& D-0.8 S q OWNER PHONE# ADDRESS CORPORATE OWNER- Co Le S j6r !�e_ 7.0,(1 CORPORATE ADDRESS: ES 9 PERSON IN CHARGE OF DAILY OPERATIONS*. U6 V M Zok- List(2)Certified Food Protection Managers AND at least(1)Allergen Awa reness areness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. "ATTACH COPIES OF CERTIFICATES" The Health Div. will -' I NOT use past years' records. You Must provide new P copies and POST THE CERTIFICATES at your Oft — food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. -0 t A— 1, 2. GLO Q/ r 6 Y/ 20 2, SIGNATVRE OF APPLICANT DATE ***FOOD POLICY INFORMATION"* SEASONAL FOOD SERVICE-All seasonal.food establishments, shments,including mobile trucks must be inspected by the Health Div. . 4n prior to opening" Please call Health Div.at 508462-4644tosched -gas -days i schedule your inspection. Please t(7) a 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 -ailuretQdosQwijjre result. the -v-_;%ti your Frozen Dessert Dlvt Failure I su _pgri Perimit until the above terms are,met. in -, SIQR or re oc on of CATERING POLICY; Anyone who caters within the Town of Barnstable most notify theTown by fax or mail prior to catering event You must complete a,_catering atering cater notice found at httv://www.townofbarnstable.us/healthdivision/ai)plications.asi) OUTDOOR COOKING; Outdoor cooking,preparation,or display of any food product by a fQQd establishment is prohibited, NOTICE: Permits run annually from January 1st to Dec.3 1'each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPUCAT'10-N(S.)AND REQUIRED FEES BY DEC I st. Q\Apphcahon Form\F0_0DAPP REVS-2019.doc p4 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. `. �a�nxsir,►m� Paul J.Canniff,D.M.D. 6 , 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate c +a Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 76 Issue Date: 01/30/2020 DBA: LATINOS MINI MARKET OWNER: LATINOS MINI MARKET INC. Location of Establishment: 115 CORPORATION STREET HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: 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: �- Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. HAMSTAeLF. Paul J.Canniff,D.M.D. a3 .� 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate °1 # 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: 76 Issue Date: 01/30/2020 DBA: SALVADORIAN CONVENIENCE STORE INC OWNER: LATINOS MINI MARKET INC. Location of Establishment: 115 CORPORATION STREET HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Ci h FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent T FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: f 4 owoe� For Office Initials: Town of Barnstable "' �Q" Date Paid I 3� $ �W BARNSTABLE, : Inspectional Services In ._ Public Health Division Check# l 1°�fo ruy s Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE /•- d--2- -10 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: -��`�OS �n� ADDRESS OF FOOD ESTABLISHMENT: S Ca�C ie o C���bd1 rJT • �"1 Arn►S �0.. 6 7-6 O 1 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �S S. a. o r O o 1C ��{ �ycw�+n�� Mq• 6) E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( ) - TOTAL NUMBER OF BATHROOMS: 12 A w• WELL WATER:: YES_NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: i/ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: d. 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:Wpplication FormsTOODAPP 2020.doc �r OWNER INFORMATION: FULL NAME OF APPLICANT Lac ®c-XZa.L�Z SOLE OWNER: YES/NO D.O.B OWNER PHONE # a p— 50 S- `1 Z ADDRESS I S Q-&'O cao Ic �: �lyd v.r\\S P%a• a L6 o t c CORPORATE OWNER: La��'nnS N��^�� Mo•��k CORPORATE ADDRESS: Its Sl- PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records.'You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. N/� 1. 2. Las 14\ cMb V 2c&kk ( /3a/ Za z© SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include copies of your employees' food protection manager training certificates (at least two) and food allergen awareness training certificate (at least one.) In addition, please include the required fee amount (see fees at bottom of this page). Make check payable to: Town of Barnstable. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax copies of your employees' food protection manager training certificates (at least two) and food allergen awareness training certificate (at least one.) In addition, you must mail the required fee amount (see box below). Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. FEES: Bed & Breakfast Permit= $55; Food Service Permit 0-49 seats=$250; 50 or more seats $300; Continental Breakfast= $30; Retail Food (only TCS Foods) =$20; Retail Food Store—Less than 8,000 S.F. _ $100, more than 8,000 S.F. = $285; less than 1,000 S.F.; Retail Food Combo/Limited Prep. -$200.00; Cottage Food Industry= $75; Mobile Truck=$50; Mobile Ice Cream Truck= $35; Frozen Dessert License=$30; Additional non-refundable Fee for New Establishment or New Ownership= $100-$500(see staff), Late Fee= $10 Q\Application FormsTOODAPP REV3-2019.doc °FTNerow � � TOWN OF BARNSTABLE HEALTH,INSPECTOR•s Establishment Name: �cA_�1.� � � Date:o��� Page: of r ti OFFICE HOURS PUBLIC HEALTH DIVISION 8:06-9:30 A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MON.-FRI. 4, ,639• .• HYANNIS,MA 02601 sob-862-464a No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT Name �/ . � DatVAI Tvoe of Tvpe of Inspection 'Operation(s) Routine Address ) I Risk Food Service Re-inspection ��--t- / Level IZDW Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other-ri`a 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) ❑ �- 1 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) a� Corrective Action Required: o ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined b the Board of Health. Overall Rating ry p ❑ ❑ p ❑ Y Y ❑ 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 (FC73)(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 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=Physical Facility 2 critical violations and less than 9non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Ph y y (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address o = 29.Special Requirements (590.009) within 10 days of receipt of this order. n,4 to 8 non-critical violations C. PATE OF RE-INSPECTION: Inspect is Si atu Pri f1 30.Other 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N 1� l #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y. N U\rV\C\V-Xra`/ Dumpster Screen-1 Y N ` " r ._ Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) 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* 15 Cooling 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202:12 Additives* 3-501. g Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-]03.11 Person-in-Chazge 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 Separation-Storage Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004(11) Variance Requirements * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 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. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate Equipment* ( )( ) Pathogens* ff 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * e eatve uuzom 4-602.11 Cleaning Frequency of Utensils and Food Animals-155'F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast--130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165'F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17. Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11 A&D PHFs 165`F 15 sec* 5 Receiving/Condition ( ) ( ) 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3 403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70OF 3-202.18 Shellstock Identification ( ) r5. Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45`F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41'F/45'F Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying DevicesPhysical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 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. ccv � � °F,HEr TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: S L U 7� C7TIC Date: a g e: of '4 OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �p ,639.A 0� HYANNIS,MA 02601 _ ,_(1. M 5088- -FRI.62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY . (� 'FDN1 FOOD ESTABLISHMENT INSPECTION REPORT UuV i Name �.,1. �� Date a of s c ion Operation(s) Routi Address . I Risk F66B,Service Re-inspection Level < Retal 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 In: Other Inspector ` Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities CV 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 Asa Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items] Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No s 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 less than non-critical violations if no critical violations observed,4 too 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address a non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 n-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspe I to \ . 31.Dumpster screened from public view f Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining y N PIC's Signature Print: Self Service ' Wait Service Provided Grease Trap Size Variance Letter Posted Y N C vZ��2 0� � Dum ster Screen . Y N Violations related to Foodborne Illness- - - - Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(]) Raw Animal Foods Separated from 3-202'12"`•- Additives* j 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and-Cold Holding _ 2-103.11 Person-in-Charge Duties 3-302".14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F - 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 590.003(C) Responsibility of the Person-.in-Charge to _ - 7-102.11 Common Name-WorkingContainers* 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* 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 of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations * 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(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(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment _ * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective vuzooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A D Violations of Section 590.009 A D m cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) ( )-( ) * 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,In[ac[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 R radices should be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* C Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity* 3-403.11( ) Y Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention 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 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140'F to 70°F 3-203.18 Shellstock Identification ( ) g Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures I 6-301.11 -- Cleanser,-Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .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 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. f HEALTH INSPECTOR'S Establishment Name: ( ; ``�"��J Date: off/ Page: °FT rower TOWN OF BARNSTABLE OFFICE TH INSPECRS TOR'S 9 of PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified � HYANNIS,MA 02601 08-8 -FRI.62-4644 508-8 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECT ON REPORT Name Dat Type of s ction Operation(s) Routine Address J/,r ' Risk Food4ervice Re-inspection r Level e_t._. TP Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person i arge(PIC) Time Bed&Breakfast HACCP ! \ In: Other Inspector yr, 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) ❑ �� l FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 1 EMPLOYEE HEALTH PROTECTION FROM CHEMICALS Izr- ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling - ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY Lo b ❑ 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) �i rrective Action Required: ElNo es 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 a items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations if no critical violations observed,4 too 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 ation,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: Ins ecto i at Pri 31.Dumpster screened from public view }, Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N - #Seats Observed PIC's Signature Print: Frozen Dessert Machines: Outside Dining Y N g Self Service Wait Service Provided Grease Trap Size Variance Letter Posted, Y N eL�Z �) b a}�7,� �� Dumpster Screen? Y N l� lY, Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202:12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*7-102.11 Common Name-Working 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 Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Se 3-501.16(A) Roasts Held At or Above 130°F* Separation-Storage* Applicants* 3-302.11(A) Food Protection* p g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice 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* q Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 1 Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* e/f cnwe 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 3-40 1.11(A)(2) I 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* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-40 1.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17. Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g• g 1= 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* 3403.11 C Commercial] Processed RTE Food-140'F* (Blue Items 23-30) 3-202.11 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* * 13 Handwashing Facilities 3-501.14 A Cooling 3-202.18 Shellstock Identification ( ) g Cooked PHFs from 140°F to 70°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 1 Town of Barnstable Building Department Brian Florence, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Pre-application for Business Certificate Date. L `7— O Ma _5 Parcel V Applicant Information Applicants Name Lo G O"RZ c%Z CZ" Applicants Address 5 S act\,t-o o K a Email Address a o n z_z�,Le r ( Zo c 8' 4�j o LA 16,9k•cc,r� H y a v.,•.�c ,v�.B.. o z F,o Telephone Number 7- "L Listed ❑ Unlisted ❑ 7� Business Information New Business? es No Business is a registered corporation? ________________________. es No If yes Name of Corporation L c% - �n oS /0.Y k ^C Does business operate under the registered corporate name`s Yesj No Is the business a sole proprietorship or home occupation? ________��- Yes No If yes then a Home Occupation Registration is required-See Building Division Staff Name of Business Business Address ( (S l'�r�p6 va,\'t, V 10 Type of Business co- Building Commissioner O f ce Use Only Conditions ,nj S r Building Commissi'P Date " Clerk Office Use Only 8 4— '-t TRESU f IRS DNTERNTALNREVENUEESERVICERY CINCINNATI OH 45999-0023 Date of this notice: 01-27-2020 Employer Identification Number: 84-4459784 Form: SS-4 LATINOS MINI MARKET INC Number of this notice: CP 575 A' 115 CORPORATION ST HYANNIS, MA 02601 For assistance you may call us at: 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN) . We assigned you EIN 84-4459784. This EIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 1120 04/15/2021 If you have questions about the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year) , see Publication 538, Accounting Periods and Methods. ` We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue) . Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. IMPORTANT INFORMATION FOR S CORPORATION ELECTION: If you intend to elect to file your return as a small business corporation, an election to file a Form 1120-S must be made within certain timeframes and the corporation must meet certain tests. All of this information is included in the instructions for Form 2553, Election by a Small Business Corporation. THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) i M -A- C(, �� L DATA 1 i y 1 1 r* i 1 . 1 3 t � i i666 1.�,,,,I F i s �� 3 � ----—L ? j I i 3 d r ! J11. era i C'd 1;L_(_ ', oon-7 a F SP�D/1'e ax y wA4L- E S I mini S-IAI - ! r� • �ouyrc ti 8 qdb� s HeL �5 >a �2-- > Z N - I z U Z � ° z z U. J C 770�t I ! f 1 C) > > r' if.r t I I l9i fi r ^ Q . o Q I x rs 7a ul E-R tk Z �n O p' 71 + 4 6 t I t l U: '4 SFtE!VES 5HELVES i I I I I I � AN-- = .M.. - EX15tinq Proposed Floor Plans Date. 03. I G-20 A i 5ALVADORAN MARKET/FOOD 1 15 Corporation Street, H ann15, MA 0260 I L/ 221. 2 2'-: Z —T; __—'T_ CD 7U ` v s: p i^� z D , I4 T 1 7d / � I < °S � i COUh`TFR i z X r s i I •j COUNTER. 1 A Q i n r ` � Sys e 5nE!`;E5 Y-FLVFS `< 71 I a z 1 1 1 ` tp z —7 r es ;In Proposed Floor Plans Date: 03. 1 G.2016 La Casa 5tud1O )ORAN MARKET/FOOD fti,Box. 1CIG-tta;�N n.��i, eS� oration Street, H annls, MA 0260 i E-V P R C P L 0-116- L 1.6�61-rar-'s IMITED RESIDENTIAL WARRANTY TER MS AND .CONDITIONS Hardwood, Engineered, Laminate, Bamboo, Cork, Tile, Vinyl, CCP, and EVP WHO'S COVERED: As the original purchaser of your floor from Lumber Liquidators, you are covered by this warranty. This warranty is not transferable, Not all'Deal' or'Major Brand"purchases have warranties. Unfinished flooring and natural stone tile products have no warranty coverage and are sold as-is. If not so indicated on the invoice,your floor purchase has no warranty. LENGTH OF COVERAGE: This limited residential warranty is valid from the date of purchase of the flooring up to the number of years indicated on your invoice. Lifetime is defined.as the lifetime of the purchaser for as long as he or she.owns the flooring. Flooring may or may not have a commercial warranty-for details go to.www.lumbediguidators.com. WHAT'S COVERED: Hardwood, Laminate, Engineered, Cork or Bamboo flooring is warranted against finish wear from normal household. conditions resulting in the exposure of the bare wood,paper layer,cork or bamboo,as applicable.With the exception.of"Major Brands"and"Deals it is also warranted against grading,.finishing and milling.defects in excess of the applicable waste factor.Waste factor is an industry term that refers.to an allowance for manufacturing and natural defects in flooring and is represented by a.percentage.While board selection may vary according to personal preference, waste is determined.by NWFA(or NALFA. if applicable) standards. Generally;waste:wll be no more than 5%to 10% of the total square footage of your purchase, however, waste may be higher based on room layout product description or product grade. "Major Brands" and "Deals" warranties,if any,are.limited solely to finish wear,do not cover manufacturing defects and are sold as is. Tranquility Vinyl floor is warranted against finish wear from normal residential use conditions resulting in wearing through the decorative finish and water damage resistance under normal residential use conditions, it is also warranted against grading finishing and milling defects.in excess of the applicable waste factor as defined above.Generally, waste will be no more than 5% of the total square footage of your purchase. However, waste may be higher based on room layout or product description.Tranquility vinyl peel and stick is also warranted against edge curling. CCP and EVP flooring is warranted against finish wear from normal residential use conditions resulting in wearing through the decorative finish and water damage under normal residential use conditions, it is also warranted against grading, finishing, and milling defects in excess of the applicable waste factor as defined above. Generally,waste will be no more than 5%of the total square footage of your purchase. However,waste,may,berhigher based on room layout or product description. Ceramic or Porcelain tile is warranted to be free of manufactured defects,and it will.not fade due to.sunlight exposure. MAY 2 2 2010 WHAT'S NOT COVERED: Jf Moisture (or Lack of Moisture): Damages caused by moisture (such.as leaking pipes, spills, wet mopping pets, relative humidity, subfloor moisture etc.) are excluded. Moisture (and dryness) can cause issues such as checks, cupping, crowning, warping, buckling, peeling, twisting, seam swelling or gapping. In addition, moisture intrusions from concrete hydrostatic pressure;flooding,or plumbing leaks, along with high levels of alkalinity, can affect flooring and subflooring over time and moisture can be trapped below the flooring and/or underlayment and create mildew or mold. Damage from such conditions,including to the floor and subfloor,is not covered under this warranty. Other Site and Environmental Conditions: Defects or damages resulting from site conditions (such as extreme heat, radiant heat, or exposure to sand); indentations and scratches (caused by pets, furniture, appliances, tools, heels, toys, etc.); improper maintenance and accidents; misuse and abuse; and any wear that conflicts with the care instructions(available at www.lumberliauidators.com)are hot covered.Cracked tiles due to misuse,poor installation,subfloor movement or unevenness are not covered. Gloss reduction: Fading or loss of gloss(or glaze)is not finish wear and not a product defect. Within the waste factor: Defects in flooring that do not exceed the waste factor are not covered under this warranty. Consequently, it is recommended that you add the applicable percentage to your total square footage when ordering your floor. Other finishes: This warranty covers the factory applied finish. Applying another finish and/or sanding (such as in preparation for another finish) may damage the factory applied finish and voids the warranty,against finish wear.' Improper Installation: Damages caused by any installation(regardless of the source of the installation advice)which conflicts with the applicable product installation instructions available at.w .lumberliauidators.com and/or the floor industry.standards of.the.NWFA, TCNA or NA (when applicable)are excludedww from-this warranty. For example,damage caused by sub-surface,sub-flooring and jobsite environmental deficiencies;improper transportation,acclimation and storage;damage,and bumps or surface dimples created by nailing machines or staples are not covered. Non-Traditional Installations: For example, intricate patterns, installations on walls or ceilings;exterior use, and usages for purposes other than flooring(like furniture or countertops)void this warranty, Boards Installed.with Visible Defects: If you see any board with defects, DO NOT install it. This includes visible manufacturing, natural or other defects. Natural Characteristics: Wood and bamboo are natural products. They may change as a result of the conditions to which they are exposed including seasonal and environmental factors. Seasonal gapping due to expansion and contraction in heating and non-heating seasons may occur. Color changes due to aging or exposure to UV/sunlight may also occur. In addition,natural variations from board to board,like differences in grain,color, tone,and knots,may exist. Issues relating to these natural characteristics are not covered under this warranty. Color and Shade Variations: New or replacement flooring may not always match samples, printed color photography:(including websites and catalogs),existing flooring or other wood products(such as cabinets,stair railings,trim and moldings)due to, among other things, natural variations that occur in species, age, growing conditions, exposure to UV/sunlight and other factors. Consequently,.these variations should be expected. Shade variations are an inherent trait of porcelain and ceramic tiles. Inspect product before installation Claims for color and shade variation will not be accepted after the product is installed. Odd Lots & Third-Party Purchases: An odd lot is flooring that is discounted.because it did not pass our rigorous inspection.process.and is not covered under this warranty.Additionally, only purchases made directly from Lumber Liquidators in store,online or by phone are covered by this warranty. Special, Indirect or Consequential Damages: Losses, damages or expenses relating to anything other than the floor itself are not covered. For example, personal damages/costs.that may arise while pursuing a quality issue,such as missed time from work,hotel stays,storage fees, kennel costs for pets, etc., are not covered. Further, costs relating.to the removal of defective flooring or installation of replacement flooring are not covered under the warranty. Some States do not allow the exclusion or limitation of incidental or consequential damages, so the above limitation or exclusion may not apply to you.Countertops,cabinets, built-in appliances.or other fixtures should:not be installed on top of your floor and the cost of the removal or replacement of these items is not covered. Radiant Heat: Any flooring installed over radiant heat that is,not installed according to the radiant heat manufacturer guidelines, product installation instructions and NWFA, NALFA,or TCNA installation standards,,as applicable,are,not covered by this warranty. (Tile) Other Materials:Grout mortar,crack isolation membranes,moisture barriers, and other materials used to install your porcelain or ceramic tiles are not covered. Grouts, selling materials,and other tile installation products may have individual warranties.These additional materials are not covered under this warranty.Check with the retailer or manufacturer of these materials for their express.warranties. HOW TO MAINTAIN YOUR WARRANTY: Follow the Pre-Installation Requirements: Prior to installing a single board or tile, you or the installer must determine that the job-site environment and the sub-surfaces meet or exceed applicable industry and product standards.The applicable installation instructions discuss these standards,which include the following: • You must comply with all applicable environmental and building codes,regulations and laws. • Your installation area and subfloor must be dry,stiff and flat within industry standards.Also,use a moisture barrier according to the installation instructions and acclimate your flooring to the area where it is being installed.For all wood based floors,once acclimated and before work begins, measure the moisture content of wood flooring and subfloor with a moisture meter and document it The moisture levels between the wood based flooring and the subfloor must be 4%or less for flooring that is up to 2.25"wide and 2%or less for flooring that is over 2.25"wide. • Your installation area must be between 60 to 80 Fahrenheit with a relative humidity of 30%and 50%for at least five days prior to delivery and remain at such levels throughout the life of your floor to ensure optimum performance. Follow the Installation and Care Instructions: It is your, or the installer's, duly to make sure the installation requirements are strictly hfollowed,especially as they relate to the use of moisture barriers, installation tools such as nailers and trowels,and the evaluation.of job site conditions and moisture testing. Care instructions can be.found at www.lumberliquidators.com. For tile, only use cleaning products that are recommended by Lumber Liquidators or neutral pH cleaners specifically designed for ceramic or porcelain floors. Inspect All Boards or Tiles for Visible Defects: Boards or tiles installed with visible defects are Inot covered under this warranty. Accordingly, before installation,you and the installer should examine each piece to ensure they are satisfactory.If any are unacceptable due to color, finish,,milling or any other reason,it is up to you to determine to use them,hide them in areas like closets,trim off the imperfection,or not install them at all.You should plan on being present during installation to ensure that all required procedures are completed and boards or tiles with visible defects are not installed. It is important to inspect individual boards and to frequently step back to observe the"whole picture"before installation is completed. If quality issues are suspected before or during installation immediately contact the store where your floor was purchased or call us at 1-800-366-4204. Touch-ups During Installation: Use of stain filler or putty stick for touch-up is considered normal practice. WHAT WE WILL DO: If any portion of your floor should fail with respect to this warranty,we will provide a store credit for the purchase price paid for the defective portion of the flooring (excluding any installation costs and labor) in excess of the applicable waste factor mentioned in "What's Covered."A store credit is the sole remedy under this warranty and can be used for store product purchases only.There is no guarantee that the same or a similar product to the original flooring will be available at the time a store credit is issued or redeemed. We reserve The right to investigate,assess and validate.reported claims by,among other things,requesting samples from you.for technical analysis and performing an inspection of the flooring and installation location. UNDER NO CIRCUMSTANCES WILL WE BE,LIABLE FOR ANY INDIRECT,.INCIDENTAL OR CONSEQUENTIAL DAMAGES EXCEPT TO THE EXTENT THAT ANY SUCH DAMAGES CANNOT BE VALIDLY DISCLAIMED UNDER APPLICABLE LAW,FURTHER. UNDER NO CIRCUMSTANCES WILL OUR LIABILITY ARISING OUT OF OR RELATING TO THE PURCHASE OF YOUR FLOORING EXCEED THE.TOTAL SUM PAID BY YOU FOR THE FLOORING AT ISSUE, Some States do not allow the exclusion or limitation of incidental or consequential damages, so the above limitation or exclusion may not apply to you. HOW TO FILE A WARRANTY CLAIM: To file a warranty claim,visit the store where you purchased your floor,tail us at 1-800-366-4204,or email via the"contact us"link at www.lumberliquidators.com.Claims must be submitted within ninety(90)days of the date that the problem with the floor is first discovered. YOUR RIGHTS: The terms above. represent the sole and exclusive warranty with regard to your flooring. WE DISCLAIM ALL OTHER WARRANTIES,EXCEPT TO THE EXTENT THAT ANY SUCH WARRANTIES CANNOT RE VALIDLY DISCLAIMED UNDER APPLICABLE LAW. This warranty gives you specific legal rights,and you may also have other rights which vary from State to State or Province to Province.We maintain the exclusive right to alter the obligations and limitations of this warranty. This warranty is provided by Lumber Liquidators. Inc.,3000 John Deere Road,Toano,Virginia 23168. LIMITED LIGHT COMMERCIAL WARRANTY TERMS AND CONDITIONS {Bellawood, Casa de Colour, Builder's Pride, Virginia Mill Works, Schon, Dream Home, Morning Star, Lisbon Cork, Avella, Tranquility Click, Felsen, and Coreluxe} WHO'S COVERED: As the original purchaser of your floor from Lumber Liquidators, you are covered by this warranty. This warranty is not transferable. 'Deal', 'major brand', 'liquidation', unfinished flooring,Tranquility Peel and Stick flooring, Mayflower and natural stone tile products have no light commercial warranty coverage. LENGTH OF COVERAGE: This limited light commercial warranty is valid from the date of purchase of the flooring up to 5 years. Flooring may or may not have a light commercial warranty. WHAT'S COVERED: Hardwood, Laminate, Engineered, Cork or Bamboo flooring is warranted against finish wear from normal light commercial foot traffic resulting in the exposure of the bare wood, paper layer, cork or bamboo, as applicable. It is also warranted against grading, finishing and milling defects in excess of the applicable waste factor.Waste factor is an industry term that refers to an allowance for manufacturing and natural defects in flooring and is represented by a percentage. While board selection may vary according to personal preference,.waste is determined by NWFA(or NALFA. if applicable)standards.Generally,waste will be no more than 5%to 10%of the total square footage of your purchase, however,waste may be higher based on room layout product description or product grade. . Tranquility Vinyl floor is warranted against finish wear from normal light commercial foot traffic resulting in wearing through the decorative finish and water damage resistance under normal light commercial use conditions,it is also warranted against_grading finishing and milling defects in excess of the applicable waste factor as defined above.Generally,.waste will be no more than 5%of-the total square.footage of your purchase. However,waste may be higher based on room layout or product description. CCP and EVP flooring is warranted against finish wear from normal light commercial foot traffic resulting in wearing through the decorative finish and water damage under normal light commercial use conditions,it is also warranted against grading,finishing and milling defects in excess of the applicable waste factor as defined*above. Generally,waste will be no more than 5%of the total square footage.of your purchase. However,waste may be higher based on room layout or product description. Ceramic or Porcelain tile is warranted to be free of manufactured defects,and it will not fade due to sunlight exposure. LIGHT COMMERCIAL APPLICATIONS: Light commercial applications are defined as: small restaurant,small retail shop,waiting rooms,lobbies,office rooms,dorm rooms,and hotel rooms. WHAT'S NOT COVERED: Moisture (or Lack of Moisture): Damages caused by moisture (such as leaking pipes, spills, wet mopping, pets,.relative humidity, subfloor moisture etc.) are excluded. Moisture (and dryness) can cause issues such as checks, cupping, crowning, warping, buckling, peeling, twisting, seam swelling or gapping. In addition, moisture intrusions from concrete hydrostatic pressure,flooding;or plumbing leaks, along with high levels of alkalinity, can affect flooring and subflooring over time and moisture can be trapped below the flooring and/or underlayment and create mildew or mold. Damage from such conditions,including to the floor and subfloor,is not covered under this warranty. Other Site and Environmental Conditions: Defects or damages resulting from site conditions (such as extreme heat, radiant heat, or exposure to sand); indentations and scratches (caused by pets, furniture, appliances, tools, heels, toys, etc.); improper maintenance and accidents; misuse and abuse;and any wear that conflicts with the care instructions(available at www:lumberliauidators.com)are not covered. Cracked tiles due to misuse,poor installation,subfloor movement or unevenness are not covered. Gloss reduction: Fading or loss of gloss(or glaze)is not finish wear and not a product defect. Within the Waste factor: Defects in flooring that do not exceed the waste factor are not covered under this warranty. Consequently, it is recommended that you add the applicable percentage to your total square footage when ordering your floor. Other finishes: This warranty covers the factory applied finish. Applying another finish and/or sanding (such as in preparation for another finish) may damage the factory applied finish and voids the warranty against finish wear. Improper Installation: Damages caused by any installation(regardless of the source of the installation advice)which conflicts with the applicable product installation instructions available at www.lumberliauidators.com and/or the floor industry standards of the NWFA, TCNA or NALFA (when applicable)are excluded from this warranty. For example;damage caused by sub-surface,sub-flooring and jobsite environmental deficiencies; improper transportation, acclimation and storage;damage,and bumps or surface dimples created by nailing machines or staples are not covered. Non-Traditional Installations: For example,.intricate patterns, installations on wails or ceilings,exterior use, and usages for purposes other than flooring(like furniture or countertops)void this warranty. Boards Installed with Visible Defects: If you see any board with defects, DO NOT install it.This includes.visible manufacturing, natural or other defects. Natural Characteristics: Wood and bamboo are natural products. They may change as a result of the conditions to which they are exposed including seasonal and environmental factors. Seasonal gapping due to expansion and contraction in heating and non-heating seasons may occur. Color changes due to aging or exposure to UV/sunlight may also occur. In addition,natural variations from board to board,like differences in grain,color, tone,and knots,may exist. Issues relating to these natural characteristics are not covered under this warranty. Color and Shade Variations: New or replacement flooring may not always match samples, printed color photography(including websites and catalogs),existing flooring or other wood products(such as cabinets, stair railings,trim and moldings)due to,among other.things,natural variations that occur in species, age, growing conditions, exposure to UV/sunlight and other factors. Consequently, these variations should be expected. Shade variations are an inherent trait of porcelain and ceramic tiles.Inspect product before installation Claims for color and shade variation will not be.accepted after the product is installed. Odd Lots & Third-Party Purchases: An odd lot is flooring that is discounted because it did not pass our rigorous inspection process and is not covered under this warranty. Additionally, only purchases made directly from Lumber Liquidators in store,online or by phone are covered by this warranty. Special, Indirect or Consequential Damages: Losses, damages or expenses relating to anything other than the floor itself are not covered. For example, personal damages/costs that may arise while pursuing a quality issue,such as missed time from work, hotel stays,storage fees, kennel costs for pets, etc., are not covered. Further, costs relating to the removal of defective flooring or installation of replacement flooring are not covered under the warranty. Some States do not allow the exclusion or limitation of incidental or consequential damages, so the above limitation or exclusion may not apply to you. Countertops,cabinets,built-in appliances or other fixtures should not be installed on top of your floor and the cost of the removal or replacement of these items is not covered. Radiant Heat: Any flooring installed over radiant heat that is not installed according to the radiant heat manufacturer guidelines, product installation instructions and NWFA, NALFA,or TCNA installation standards,as applicable,are not covered by this warranty. (Tile) Other Materials: Grout mortar, crack isolation membranes, moisture barriers, and.other materials used to install your porcelain or ceramic tiles are not covered. Grouts, selling materials,and other tile installation products may have individual warranties.These additional materials are not covered under this warranty.Check with the retailer or manufacturer of these-materials for their express warranties. HOW TO MAINTAIN YOUR WARRANTY: Follow the Pre-Installation Requirements: Prior to installing a single board or tile, you or the installer must determine that the job-site environment and the sub-surfaces meet or exceed applicable industry and product standards.The. applicable Installation instructions discuss these standards,which include the following: • You must comply with all applicable environmental and building codes,regulations and laws.. • Your installation area and subfloor must be dry,stiff and flat within industry standards.Also, use a moisture barrier according to the installation instructions and acclimate your flooring to the area where it is being installed.For all wood based floors,once acclimated and before work begins, measure the moisture content of wood flooring and.subfloor with a moisture meter and document it The moisture levels between the wood based flooring and the subfloor must be 4%or less for flooring that is up to 2.25"wide and 2%or less for flooring that is over 2.25"wide. • Your installation area must be between 60 to 80 Fahrenheit with a relative humidity of 30%and 50%for at least five days prior to delivery and remain at such levels throughout the life of your floor to ensure optimum performance. Follow the Installation and Care Instructions: It is your, or the installer's, duty to make sure the installation requirements are strictly followed, especially as they relate to the use of moisture barriers, installation tools such as nailers and trowels,and the evaluation of job site conditions and moisture testing. Care instructions can be found at www:lumberliauidators.com. For tile, only use cleaning products that are recommended by Lumber Liquidators or neutral pH cleaners specifically designed for ceramic or porcelain floors. Inspect All Boards or Tiles for Visible Defects: Boards or tiles installed with visible defects are not covered under this warranty. Accordingly, before installation, you and the installer should examine each piece to ensure they are satisfactory. If any are unacceptable due to color, finish, milling or any other reason,it is up to you to determine to use them, hide them in areas like closets,trim off the imperfection,or not install them at all. You should plan on being present during installation to ensure that all required procedures are completed and boards or tiles with visible defects are not installed. It is important to inspect individual boards and to frequently step back to.observe the"whole picture"before installation is completed. If quality issues are suspected before or during installation immediately contact the store where your floor was purchased or call us at 1-800-366-4204. Touch-ups During Installation: Use of stain filler or putty stick for touch-up is considered normal practice. WHAT WE WILL DO: If any portion of your floor should fail with respect to this warranty,we will provide a store credit for the purchase price paid for the defective portion of the flooring (excluding any installation costs and labor) in excess of the applicable waste factor mentioned in "What's Covered."A store credit is the sole remedy under this warranty and can be used for store product purchases only.There is no guarantee that the same or a similar product to the original flooring will be available at the time a store credit is issued or redeemed. We reserve the right to investigate, assess and validate reported claims by,among other things, requesting samples from you for technical analysis and performing an inspection of the flooring and installation location. UNDER NO CIRCUMSTANCES WILL WE BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGES EXCEPT TO THE EXTENT THAT ANY SUCH DAMAGES CANNOT BE.VALIDLY DISCLAIMED UNDER APPLICABLE LAW.FURTHER. UNDER NO CIRCUMSTANCES WILL OUR LIABILITY ARISING OUT OF OR RELATING TO THE PURCHASE OF YOUR FLOORING EXCEED THE TOTAL SUM PAID BY.YOU FOR THE FLOORING AT ISSUE, Some States do not allow the exclusion or limitation of incidental or consequential damages, so the above limitation or exclusion may not apply to you. HOW TO FILE A WARRANTY CLAIM: To file a warranty claim,visit the store where you purchased your floor, call us at 1-800-366-4204, or email via the"contact us"link at www.lumberliquidators.com.Claims must be submitted within ninety(90)days of the date that the problem with the floor is first discovered. YOUR RIGHTS: The terms above represent the sole and exclusive warranty with regard to your flooring. WE DISCLAIM ALL OTHER WARRANTIES, EXCEPT TO THE EXTENT THAT ANY SUCH WARRANTIES CANNOT RE VALIDLY DISCLAIMED UNDER APPLICABLE LAW. This warranty gives you specific legal rights,and you may also have other rights which vary from State to State or Province to Province.We maintain the exclusive right to alter the obligations and limitations of this warranty, This warranty,is provided by Lumber Liquidators. Inc.,3000 John Deere Road,Toano,Virginia 23168. . Legend ' " • Road Names fw -kf 4 'S { �LeY�i�•r <$• 40 n: VI uek CJW-'40 -".`+wa4�, !. i. 6 Y <-•_ . u &.�: ��:i'JG�{ Ys� ', a� n'&�..xs� ��" w" "�� � �+"�' far '�• #iji R� p''k�� -� , �`� ,� I � y� 'h'r�"` `y$ 4 _ ;� �•a;, {��, ��.►r,,. 2��y3'J@ �� ' .^mow-1 ,�" ,cam-.+.� ,� ` �{� r k r,: tF4 �: �•-. ,��.. . �. Al � � � � dui"dNk"� � r� � w. '�`�'°''Tn, ,�r 2..� �r '�'r a�. • Y A-yY .,v.�e .a yr' a � �� -`�"''�.,'' J•'��; mat'• t" ,:3 i '"� x. r .,..{����� .6 ��� '� �"y � •n. T3' 1.,.�.1 ��'�,n � ��d]- ram, i � � � 0• Map printed on: 1/22/2o18 - This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026oi O 42 83 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map So8-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale:i inch= 42 feet 0 cartographic errors or omissions. gis@town.barnstable.ma.us 1 x t No....2...:...... ... 0 Fxs.... ....2 .:...�_ 1 , THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town Barnstable .. .....................OF.......................................... Appliration for Uhipaii al i9orkii Tvaastrurtiaan rumit Application is hereby made for a Permit.to Construct ( ) or Repair X(XX) an Individual Sewage Disposal System at: 115 Corporation' Road Hyannis ................_................................................................................ ----•-------._.............__.........------------•----•---------...-•------•--------------------- Location-Address or Lot No. Goldstein ----•.................---..........----------•-........---------------------------------------.-- .........._....................................................................................... Owner Address W J.P.i`Zaccin'z�er Installer Address Type of Building Size Lot---.-------_--------------Sq. feet U Dwelling—No. of Bedrooms................................. _Expansion Attic ( ) Garbage Grinder ( ) No, of persons............................ Showers — Cafeteria pa,, Others Type of Building _________________________ p ( ) ( ) d Creative Bakery Other fixtures ------------------------------------------------------------------------•-------•---------------•------------------•------------•------..........---- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water--..---____-_-__-_--_ LT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------.................. a' ---•----•---•---------•------------------------------------•----....---------..........------------.------•-•-...............------------••--•...------------ Descriptionof Soil. s.and_..---•--•----•---•--••-------------------------------------------------------------------------------------------- x U -----------------•-•------------••-•---...------•---•-----------------------•-•-----------------------------------------•--------------------•._...--------------------------------•--•---------------- w U Nature of Repairs or Alterations—Answer when applicable_.-_---__.--••_._-___--•- - - - --- -------------------------------------------------- 1-1000 gallon grease trap ---------------------------------•--------------------------------------------------------•-•--....-----...-----------------------------------------------------------------------------........_...---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 11 1:E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued y e b ��d of heal . Signe �t/ r% -- 1/2 5/89 .................. Date Application Approved By..------.. a,.. --= _...... ---------- Date Application Disapproved for the following reasons--------------------------------------------•----------------------------------•---------------------•----•--•- -•-•-•---......--•--------------------------------------------------------------------------------------•..-----------------------------------------•--•------------------•------------------------------ p Date PermitNo..------...li_.%_A.G -------•--------------- Issued....................................................... Date 20.00 No......................... ............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -To��r -....OF..........BarrlstalL�.s Applutttiun for viapusttl Works Tamitru.rtiun 1hruti# Application is hereby made for a Permit to Construct ( ) or Repair ` X ) an Individual Sewage Disposal System at: 11`. •-•---•-•••-•-••••----••-•--•-------........-•-•-........-•------•-•••..............-•-----••-•--- Location-Address or Lot No. i:ic11 Owner Address a7 ,1 ,Tiacom:�e Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '04 4 Otherl,=XType of Building ^ .. No. of persons............................ Showers — Cafeteria Balser � ,. . Other fixtures -------------r...xbiv-----------•--------•-------------------------------------------------------------------------•-•------•--•--...---------.........---••- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. OWxG Septic Tank—Liquid Li uid capacity......_._...gallons Length-__--__.•_..._.. Width................ Diameter.........._..... _.....__.__..... Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching-area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '"' Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-_-_----__-____..__--_. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....__--__-___---_-___- a --••-•••---•-------------••--------•-•••-••-------•--------------••.......---------------------••-----•-----••-•---•........................................ ODescription of Soil------------------------------------------- -i1-?....------•-•--••---•----•••-••--••••-•---•••--•---•-••--•-••---•••••••-•••••••••••------•--...--------------•••- x V -•------•••-•--•-•••--•--••••••-•-----••----•--•---...-•-•-••••-•-•-•-••-••-••-•-••--•-------•-•---•.....----•••-••--•-----•••••----••--•--•---•-------••••-••-•--•-••••••--•--•..........•--•----•--•-- W U Nature of Repairs or Alterations—Answer when applicable.......... -n "t --•-----•---------------------------------------•----------------•------•-------------------------------------•----------------------------------------------------------------------...------....--•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT .;. ,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. j > r' - 1/25/S9 Signed ! rb {,L,•,ry ---•----------•--- ---------- - -- Application Approved B � ___ !. ......................................................F \ l .. 2 _..' Date Application Disapproved for the following reasons------------------•---------...------._...--------------•----•--------------------------•----•••-•-•-------•..._ ---------------------------------•-------....---•--••----------------------------------............-----..................-----•--.•-•-- -••-•••-•-------•-•-•-••-•-••--•--••••----•----•---•--••...... .. O � G '�) Date Permit No.......................................................... Issued•---------------.---- ---------------------------------- L:.L.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ..........................................OF..................................................................................... Torrtifirtttr of Tomphatt r X.r THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( } b J..-P...`4aooribe;' y---- ------ ----------------•--.. 115 Corporation Road H�ra.inis Installer at........................................................................----•-•-----•-•-----•••----- •••••••-•-----•-----•-----•••-----••....... has been installed in accordance with the provisions of TIT ---=/5.tf T-e State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Barnstable y. 3 ..Town 2, .: No......................... FEE........................ Diapollat,lyi rruti Permission is hereby granted......................................................................y . _............ to Construct (, )_or Repai�r(a )XaonnIn li'i�duall,S�e Tagp;Disposal Systecri atNo..............................•---• -•••---------.0.a......0a. V.....----------- Street as shown on the apl licaQ�iV.fo"isposal Works Construction Permit No..:.................. Dated.......................................... ................••------•------------------------------------------------...---•-...._.......--•--••---- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - R DG . I!`..�COU LATER, ,,I ,- _ _ - _ _ _ _ TO REMAIN �. STORAGE WALK-IN REF. WALK-IN REF., d h; I SHELVES TO BE REMOVED r r TO REMAIN TO REMAIN c D REMOVED I !i 4-N �7 I \ I HEAVY-DUTY RAIL BEAM rie' + f I J TO BE REMOVED e� r � � HEATING SYSTEML-1C5/EILING Ln O 0 TABLE r - SHELVES, - IVONE CAKES , I TABLE TO BE (REMOVED" - TO FEMA N � X I VINYL FLOOR \ KITCHEN p _ I s AX/ _ TO BE REMOVED VINYL FLOOR N A INSECT-5dREEN DOOR N -- L _ J WOOD PLATFO><'M p WOOD DOOR TO REMAIN c�! OVEN / ' I x � T B REMOVED — J O E R O CASHIER .. �. \A AT 'XI/r' � f \COUNTER - - - ._.._ - - - - - - - _..: .._ - _..;.. - - o I ELECTRIC PANELS � N L- - - - - - - - - - - - - - - - - - - -- WALK-IN SEPTIC PIPE flLADIES CA00 0C MEN TO REMAIN SINKS ECOUNTER N ItIN Ih S�. , a i GAS METER' { 251-5a,� � , 42'-GIu Q G91-- 10_l 11 2 EXI5TI NG FI R5T FLOOR PLAN SCALE: 1 14°= 1'-0 N O IZTI LEGEND EXISTING WALL TO REMAIN EXISTING WALL TO BE REMOVED EXISTING COUNTERS TO BE REMOVED ttn V ] SQUARE FOOTAGE EXISTING BUILDING 15GO SQ. IT. (' - EXISTING KITCHEN = 975 SQ. IT. NEW RANGE AND RANGE HOOD EXISTING IVONE CAKES 585 SQ. FT _' NEW GRILL AND E RIDGE UNDER SHELVES F IDG E FRIDGE FP,EE ER ARMS R -= WALK-IN REF. WALK-IN REF. - © z NEW KITCHEN if SHEL LS � tS} VINYL FLOOD { n - 9'-3" C� f I - O 1 4 5 �� 2 3-G 5T INLESS ST EL ------ oe_._.-.._ 00- TABLE r_ - - 1 5INELVE5 I NEW I — LIT I p STORAGE I I ICE VE SHE VE HE VE SHE VET' SHE VE LuI' � - — WOOD PLATFORM _ NEW 511 EL E5 5T I N LE55 ST EL — MINI MARKET " VINYL FLOOR _. .�. TABLE - - 40 WAT_ (� - - - - - — - - — — — / t-1EA I i CASHIER I - J / 4� WALK-IN FREEZI=R <1 SINKS LADIES MEN 5� - SHELVES NI- E WS 1 i 1 GAS METER t1 � I 371- I I ° 301- 1 " Ln I Q G9- IO2 I PROP05FD FIR5T FLOOK PLAN � NORT # SCALE: 1/4 1 '-0" LEGEND EXI5TI NG WALL TO REMAI N NEW WALL i SQUARE FOOTAGE EXISTING BUILDING = 15GO SQ. FT. PROPOSED KITCHEN AREA/RESTAURANT = G90 SQ. FT.I5TORAGE: I GO 5Q. IT, PROPOSED MINI MARKET/RETAIL 870 SQ. FT: '' it