HomeMy WebLinkAboutLUKE'S LIQ OF 132 - RETAIL FOOD LUKE's LIQ of 131,-
a'�14:-.
1166 Iyann Rd, Hy Q,00
� T Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli, M.D.
BARNSTAut.e, F.P.(Thomas)Lee
MA&k Daniel Luczkow,Alternate
30)4. .� ' 200 Main Street, Hyannis, MA 02601
� Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Sell Tobacco
In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General
Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is
hereby granted to:
Permit No: 52 Issue Date: 1/1/2021
DBA: LUKE'S LIQUORS OF 132
OWNER: AJ LUKES OF HYANNIS INC.
Location of Establishment: 1166 IYANNOUGH ROAD HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2021
TOBACCO SALES: $85.00
Permit Expires: 12/31/2021
ca,
Restrictions: Thomas A. McKean, RS, CHO, Health Agent
PLEASE POST CONSPICUOUSLY
For Office Use Only: Initials:
Town of Barnstable
AB Inspectional Services Date paid t� 2d$BMA
�AtMAN.
Public Health Division Check
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT PERMIT.APPLICATION(Non-Flavored).
DATE J NEW BUSINESS OWNERSHIP RENEWAL
t
NAME OF TOBACCO ESTABLISHMENT: 1
ADDRESS OF TOBACCO ESTABLISHMENT: . IdAia
NY�I�L4S
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): oQa 51pewCcee ZIP/. Gy VGtVYVIOtI�� � .1m�'.b2�°73 x'.
P
E-MAIL ADDRESS: r )wAt 13.2 (:W l L kes mx2e cock,an m IX
f
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: -77 - � V\
/7 l y- 1?96- d&QS'
OWNER'S NAME:, 12—0t -T. IL4 ke- Rt1e5. OWNER'S PA&rr '
OWNER'S ADDRESS: 45 C✓��Sb� Sr �� frv�a c.�f� vial �
CORPORATE NAME' •T �L,PS4(,�� p �
ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO 1 /
z
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)..
s
TOWN OF BARNSTABLE CODE/MA GENERAL.LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360,com/33996392
MA GENERAL LAW CHAPTER 270/SECTION 6: I
https:Hmaleyislature.Eov/Laws/GcneralLaws/PartlV/Titlel/ChMer270/Section6
***NEW BUSINESSES AND NEW OWNERS ONLY***
REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED.
PLEASE CALL 508-375-6621
FALL APPLICANTS ARE REQUIRED TO SUBMIT.THE FOLLOWING REQUIRED DOCUMENTS:
1) MA State License to Sell CIRArettes 3) IRS Federal Tax ID#Document
2) MA State License to Sell C' rs a d Smokird T bacco 4) Payment of Fee(s) -see page 4
j -
SIGNATURE:
PRINTED NAME: DATE:.
Q:1Application Forms\TOBACCO APP-NonFavor 12-18-19.docx
v
Ll/�S D� �Gr Cod
ESTABLISHMENT'S NAME
T®BACC® SALI:S
NO XJann&J6111.
Employee Signature Form
This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of
the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the
penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section
371-9.of the Town of Barnstable Board of Health Regulation:
Sales to Minors—&.371-9. Sale and Distribution of Tobacco Products.
1. No person shall sell or provide a tobacco product,as defined herein,to a person under
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
2. Identification: Each person selling or distributing tobacco products,as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of
Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws:
Si natur Prin ed Name Date
i a e Printed Name Date
Oh
Signature Printed Name Date
41 J
Sig 'a"1 e Printed Name Date
�Si re Printed Name Date
Py^y�.
Signatur Printe Name Date
2
Signature rinted Name Date
Q;\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx
91
Commonwealth of Massachusetts Letter ID:L0568669760
s Department of Revenue Notice Date:September 1,2020
p � Geoffrey E..Snyder,Commissioner Account ID:CGL-10617399-003
resk� mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
��I�iii��I�iI��IIII�IIi�iII��I��I�II��i���s�II�I�IIIaeIeIIIIeBI�I
o=
A.J.LUKE'S OF 132,INC.
W= 40 CROSBY STREET EXT
BASS RIVER MA 02664-4515
Attached below is your Retailer License for Sale of Cigarettes (Form CT-3). Cut along the dotted line
and display at your business location. At any time,you can log into your MassTaxConnect account at
mass.gov/masstaxconn-.ct to view and re-print a copy of this license.
If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at
(800)392-6089, Monday through Friday, 8:30 a.m.to 4:30 p.m.
DETACH HERE
•-----------------------------------------------------------------------------------------------------------------------------------------------
SsKCH sF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
1p
M , Retailer License for Sale of Cigarettes
�i NI 01. This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
A. J. LUKE'S OF 132, INC. Account ID: CGL-10617399-003
1166 IYANNOUGH RD License Number: 749127680
HYANNIS MA 02601-8106
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date: October 1,.2020 Expiration Date: September 30, 2022,
I
wm
Commonwealth of Massachusetts Letter ID:L1350698560
Department of Revenue Notice Date:September 1,2020
Geoffrey E.Snyder,Commissioner Account ID:CRL-10617399-006
rr6fc`z mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
I�'Illlll��l��ll�l�lslilloll��li�llill�lllll0elo�ial�l IIIIII�IIII
A.J.LUKE'S OF 132,INC.
o=_ 40 CROSBY STREET EXT
BASS RIVER MA 02664-4515
Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut
along the dotted line and display at your business location. At any time,you can log into your
MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license.
If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at
(800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
•-----------------------------------------------------------------------------------------------------------------------------------------------
�SF�A MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
1PRetailer License for Sale of Cigars and Smoking Tobacco
4i� off ' This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
A. J. LUKE'S OF 132,INC. Account ID: CRL-10617399-006
1166 IYANNOUGH RD License Number: 2096470016
HYANNIS MA 02601-8106
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date:October 1, 2020 Expiration Date:September 30,2022
Department of Treasury Notice CP261
Internal Revenue Service Notice date September 26, 2016
IDO Cincinnati OH 45999-0038 Employer ID number 81-2587855
To contact us Phone 1-800-829-0115
Page 1 of 3
031298.545195.76707.28817 1 AT 0.399 536
IAI'I'III III IIIII III IIIIIIIfeIeIIIIIIeIIIIeIIelleillelelullAlllll
AJ LUKES OF 132 INC
K; LUKES SUPER LIQUORS
Ff 6 NARROWS LN
S YARMOUTH MA 02664-2213
031298
We've acceptLed your Corporation eiectiUri
You will be treated as an S Corporation starting May 11, 2016
We've accepted your S Corporation election. What you need to do
As a result,your tax year will end in December,
and you will be treated as an S Corporation You don't need to take any action.
starting May 11, 2016. Review this notice to understand some of your obligations and responsibilities as an S
Corporation.
Continued on back...
AJLUKES 1 Notice CP261
LUKES SUPER LIQUORS September 26,2016 Notice date Se
6 NARROWS LN P
S YARMOUTH MA 02664-2213 Employer ID number 81-2587855
If your address has changed, please call 1-800-829-0115 or visit www.irs.gov.
Contact information ❑ Please check here if you've included any correspondence. Write your Employer ID
number(81-2587855)on any correspondence.
❑a.m. ❑a.m.
❑P.M. ❑P.M.
Primary Phone Best time to call Secondary Phone Best time to call
INTERNAL REVENUE SERVICE
CINCINNATI OH 45999-0038
I�Il�lni��ihll�r��ll���ll�l��lilllll�u�ll�ul�r��I�n�r����l
812-587855 JA -- 00 2 000000-- -- —
Li uafs o- CC_ 132-
Bellaire, Dianna � i
From: hyannis@lukescapecod.com
Sent: Tuesday, November 24, 2020 7:09 AM
To: Bellaire, Dianna
Subject: RE: 2021 Tobacco Permit for Lukes' Super Liquors- 395 Barnstable
AJ Luke's Super Liquors at 395 Barnstable Road does not sell any of those products.
Thank you,
Tim Walker
From: Bellaire, Dianna <Dianna.Bellaire @town.barnstable.ma.us>
Sent: Monday, November 23, 2020 4:22 PM
To: hyannis@lukescapecod.com; route132@lukescapecod.com
Cc: Bellaire, Dianna <Dianna.Bellaire @town.barnstable.ma.us>
Subject: 2021 Tobacco Permit for Lukes'Super Liquors-395 Barnstable
Importance: High
Hi,
This is confirmation that I've received your application. However,this year there is a new MA State License for
Electronic Delivery Systems, E-Cigarettes,Vaping and E-Juices. Please let me know if you sell these items, if so, I need a
copy of your Electronic Delivery Systems MA License OR I need an email that states you DON'T sell these items and I will
place a note on the account. This application will remain in pending until I receive either of those things.
Thank you.
Dianna Bellaire
Permit Technician
Town of Barnstable
Health Division
200 Main Street
Hyannis, MA 02601
P:508-862-4643
Fax:508-790-6304
Email:Dianna.Bella ire@town.barnstable.ma.us
The information contained in this electronic transmission("e-mail"),including anl,attachment(the"Information"),may be confidential or
other"vise exempt from disclosure.It is for the addressee only.This Information inav be privileged and confidential work-product or a
privileged and confidential.communication.'Ihe.Information inap also be deliberative.and.pre-decisional in nature. As such.,it is for
internal use only.The Information map not be disclosed«7thout the prior written consent of the Director of Public Health and/or the
l'olvn Attornev's Office of the Town of Barnstable. If you have received this e.-mail by mistake,please notify the sender and.delete it from.
your system.Please do not copy-or foiAvard it.Thank you for your cooperation.
1
r
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
MRWT ALE, Paul J.Canniff,D.M.D.
200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Sell Tobacco
In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General
Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is
hereby granted to:
Permit No: 52 Issue Date: 1/1/2020
DBA: LUKE'S LIQUORS OF 132
OWNER: AJ LUKES OF HYANNIS INC.
Location of Establishment: 1166 IYANNOUGH ROAD HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2020
TOBACCO SALES: $85.00
Permit Expires: 12/31/2020
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
' For Office Use.Only,• Initials:
OFTNETq,y Town of Barnstable ii
Date Paid I� Amt Pd$ �—
BAIM BLE, : Inspectional Services F
' `e� Public Health Division Check# -LASA�I chc)pti�
AlFO MA'S A
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304 "
TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored)
DATE I NEW BUSINESS OWNERSHIP RENEWAL
NAME OF TOBACCO ESTABLISHMENT.
ADDRESS OF TOBACCO ESTABLISHMENT: 11 (o� JEq a n In f�wz�) !13
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): a�c„P,f-LJV. Uj- V ai2mc9,l.+- :MA
E-MAIL ADDRESS: rOLLk 132 �,t�. .5 ati �D L'U r-n
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 7 7 -F5-U-
OWNER'S NAME: A-ei IV.ok - U.L.Vj,L OWNER'S
77 �R'S PH# - O R
OWNER'S ADDRESS: 40 �ii asb. St, 9, tl 02( a. -MA-
CORPORATE ADDRESS: �' r 0,` Q A*ORPORATE FID#
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)
TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/33 996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
https://malegislature.gov/Laws/GeneralLaws/Part! /Titiel/Chapter270/Section6
***NEW BUSINESSES AND NEW OWNERS ONLY***
REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED.
PLEASE CALL 508-375-6621
ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS:
1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document
2) MA State License to Se I Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4
SIGNATURE: VIF
PRINTED NAME: Tres)��Pl�
DATE:
Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc
o
. ��rttsF Commonwealth of Massachusetts Letter ID:L1489203840 ❑®iJF
{ Department of Revenue Notice Date:September 26,2018
' -10.J I Christopher C.Hardir&Comfnissioncr Account ID:CGL-10617399-003
tUhTU��w mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
o=
CHRISTINA A.LUKE
_ A.J.LUKE'S OF 132,INC.
CO 6 NARROWS LN
SOUTH YARMOUTH MA 02664-2213
Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line
and display at your business location.At any time,you can log into your MassTaxConnect account at
mass.gov/masstaxconnect to view and re-print a copy of this license.
If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at
(800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
-----------------------------------------------------------------------------------------------------------------------------------------------
SWHUs
Facer MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigarettes
F�°roF�� This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
A. J. LUKE'S OF 132,INC. Account ID: CGL-10617399-003
1166 IYANNOUGH RD License Number: 433391616
HYANNIS MA 02601-8106
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date: October 1, 2018 Expiration Date: September 30, 2020
y .Llul-4v Commonwealth of Massachusetts Letter ID:L2083377792 .0 0
E r= I r Department of Rcvenue. Notice Date:September 25,2018
Christopher C.Wxding,Commissioner Account ID:CRL-10617399-006
mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
CHRISTINA A.LUKE
o= A.J.LUKE'S OF 132,INC.
o—
6 NARROWS LN
SOUTH YARMOUTH MA 02664-2213
Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut
along the dotted line and display at your business location. At any time,you can log into your
MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license.
If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at
(800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
-------------------------------------------------------------7---------------------------------------------------------------------------------
X«'\+s'`T� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigars and Smoking Tobacco
z
This license must be posted and visible at all times.The sale of tobacco
'pro.
products to anyone under 18 years of age is prohibited.
A. J. LUKE'S OF 132, INC. Account ID: CRL-10617399-006
1166 IYANNOUGH RD : License Number: 1010190336
HYANNIS MA 02601-8106
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date:October 1,2018 Expiration Date:September 30, 2020
Department of the Treasury Notice CP279A
Internal Revenue Service Tax period December 31,2017
IRS Cincinnati OH 45999 0038 Notice date May 15,2017
Employer ID number 81-2587855
To contact us Phone 1-800-829-0115
Page 1 of 2
008408.756489.197655.11686 1 AV 0.373 540
IIIIuIILIIIIrIIII"III'Il'II'I'I'Iilllt'JI1!'IIIIIIIII�rrrftll)
AJ LUKES OF 132 INC
LUKES SUPER LIQUORS
1166 IYANNOUCH RD
xrs
HYANNIS NIA 02601-8106
08408
Important information abor_It you 1-r Form.8869 _
We accepted the election to treat you as a qualified subchapter s
subsidiary
We accepted the Form 8869,Qualified What you need to do
Subchapter S Subsidiary Election,filed by your
parent corporation. As a qualified subchapter S You don't need to do anything at this time.
subsidiary,your accounting period is the same as
your parent and is effective January 1, 2017.
The effective date is subject to verification and
approval of the information your parent
corporation provided.
---•---------------------------------------------•---•-----•-----...--------•----------_--•-----------•----•----------------•---------------------------
Continued on back...
A)LUKES OF 132 INC Notice CP279A
LUKES
t SUPER LIQUORS
166 IrAnuoUGH Rc
Notice date May 15,2017610
HYANNIS r,}A 02601-9106 Employer ID number 81-2587855
R L E
If your address has changed,please call 1-800-829-0115 or visit www.irs.gov.
Contact information Please check here if you've included any correspondence. Write your Employer ID
number(81-2587855),the tax period(December 31, 2017),and the form number
(1120)on any correspondence.
❑ a.m. ❑ am,
❑ P.m. ❑ P.M.
Primary Phone best 6me to cal[ Secontiary Phane Best tune to call
INTERNAL REVENUE SERVICE
C.INCINNATI OH 45999-0038
Crfrrhurrll'11'I"rl("'frlf"hilkl'rliHrnrrr"llnlr"'1'�.
812587855 JA 02 2 201712 �
I
i
Dec 10 2019 10:36AM AJ Lukes 132 7745522635 page 1
ESTABLISHMENT'S NAME
TOBACCO SALES �,16LvIOrCJ
Employee Signature Form /W I y*V/Yrd11 ,P.D
This form is for official use to indicate that the amployee(s)of this establishment received and understood Chapter 371
of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the aZd
penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section
371-9.of the Town of Barnstable Board of Health Regulation:
Sales to Minors—g 371-9.Sale and Distribution of Tobacco Products
1. No person shall sell or provide a tobacco product,as defined herein,to a person under
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
2. Identification: Each person selling or distributing tobacco products,as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The employee(s)below received and understood Section 37I-9 of the Town of Barnstable Board of
Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws:
signa Printed Name Date
w�lWH
Signiittue Printed Name Date
Signatur Printed Name Date
149L Lg4gc� . I
signa a Printed Name Date
Signature Printed Name Date
Ty
S' furs Printed Name Date
Sign Printed Name Date
6Ct
QAA"ication FZ6HflCdAPP:N6 ev�9 doc 12 ,
w
i
H-F Town of Barnstable BOARD OF HEALTH
Paul 1 Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
SARNTrA►sce =` John T. Norman
°$ 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 52 Issue Date: 12/20/18
DBA: LUKE'S LIQUORS OF 132
OWNER: ARTHUR.I. LUKE,
Location of Establishment: 1166 IYANNOUGH ROAD HYANNIS, MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR: 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: -- ------ ---- - -
MOBILE-FOOD:
MOBILE-ICE CREAM: C?�
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES: $85.00
FOR ESTABLISHMENTS WITH SEATING: i
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
INE 'c�, Town of Barnstable For Office Use Only: Initial _
Inspectional Services Cate heck id
* BARNBTAB14
639. ,.� Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-790-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
Fee: $85.00
MAIL TO: TOWN OF BARNSTABLE
PUBLIC HEALTH DIVISION
200 Main Street
HYANNIS,MA 02601
FAX 508 790-6304
PLEASE INCLUDE THE REQUIRED FEE OF$85.00
APPLICATION FOR A TOBACCO SALES PERMIT
T LcL,L,�PA 3
ESTABLISHMENT NAME (D/B1 -
1 I . k W7
ADDRESS OF BUSIN19SS
SWAIJOMfAAWL Mt7-
MAILING A DRES (IF DIFFERENT FROM AB(JVE)
OWNER'S NA E: LAST FIRST MIDDLE
cam, �v -7-75- ��
Do you currently possess a state license to sell tobacco products?
Yes V No
Each employee who sells tobacco products must receive and understand Chapter 371 of
the Town of Barnstable Code (copy provided herein) and the Massachusetts General
Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee
who sells tobacco pro cts must si n the Employee Signature Form (provided
herein): p�
Signature Date
Q:Application Forms\TOBACCO APP2019 dob.docx
e 13
ESTABLISHMENT'S NAMV
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s) of this establishment received and
understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the
Massachusetts General Laws which describes the penalties for selling and/or giving tobacco .
products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of
Barnstable Board of Health Regulation:
Sales to !'Minors—§371-9.-Sale and Distribution of TGbacco products. y
1. No person shall sell or provide a tobacco product, as defined herein,to a person under
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
2. Identification: Each person selling or distributing tobacco products, as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The following employee(s) received and understood Section 371-9 of the Town of Barnstable
Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the
Massachusetts General Laws:
Signat4re Printed N me Date
Y11A.1,11A.11, LTZ�-t A-elr(U L 00
Signature Printed Ndne Date
Sign e Pri d Name Date
P
Si/ture Printed Name Date
Signature Printed Name Date
X22) <:�e,Q1* 'Cal ' 1 l
'gn ture Printed Name Date
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�p INE low TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: U'O"Defe: -age: of
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BARE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
�A M67 a 0� HYANNIS,MA 02601 _" MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
s08-862-4644
'FOM1" F OD ESTABLISHMENT INSPEPTVON REPORT
Name Date pe of insciection
Operation(s) outine
Address �f TC_X a� #1 rj Food Service a 'on
etail Previo s
Telephone ' ntial Kitchen Date:
Mobile Pre-op a idn
Owner HACCP Y/N Temporary Suspect Illness _ -
Caterer General Complaint
Person in Charge(PI ) Time Bed&Breakfast HACCP
n Other
Inspector O
Each violation checked requires an explanation on the narrative p ge(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No FED Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items
checked indicate violations of 105 CMR 590.000/Federal Food Code. Embargo❑ ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical 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 g 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 re
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
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
be in writing and submitted to the Board of Health at the above address violations observed,7 to 8non-critic, violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008) 9 v' ,4 to 8 non-critical violatio =C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
Ins is i tu rint:
30.Other DATE OF RE-INSPECTION:
r AigA
g
31.Dumpster screened from public view n
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N C�
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signat a Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N .4�� ��.,�q
Dumpster Screen o Y N E�Gsr(.G� &i"w''►--cam
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
t Law Cooled to 41°F/45°F Within 4 Hours*
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-2G2-12- _ Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* *__ _ _ _..19 PHF Hot and Cold Holding
2-103.11 Person-in=Charge Duties - � - - - - - 3-302.14 Protection from Unapproved.Addidves - - - -- '
Contamination from Raw Ingredients i ,15 dients r Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
I '_ __ .. - _ - - � - ----- - -
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590:004(F)- - - -
2 590.003(E) Responsibility of--the Person-in-Charge to- - - - r - - - - - - - - Other* 7-h 3-501.16(A) Hot PHFs Maintained At or Above 140°F02.11 Common Name-Working Containers*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
Y Storage*
-
- -- ' Applicants*" - _ - "- 3-302.11(i1) Food Protection* 7-201.11 Separation 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 1-1 - Variance Requirements
* 3-30- Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
- - 590.003(G)- Reporting-by Person in-Charge -- - - - - �- - - - - - -
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* -REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Foam* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions g � )
Disposition of Adulterated or Contaminated
- - - - - -- - - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
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
- 4 501.1-11- 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 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.I IA(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 cri�e rnrzoot
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)(I)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Chemical Stuffing Containing Fish,Meal,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed * g g trY 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* Ratites-165°F I5 sec* in mobile food,temporary and residential
Sources � 10 Proper,Adequate Handwashing g' p �
Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under'
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-30L12 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
( )( )( )
11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
3-201.17 Game Animals* Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodbome
12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts*
3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14 Cooling Cooked PHFs from 140°F to 70°F
. (A) g
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004 J Labeling of Ingredients* Supplied with Soap and hand Drying Devices
() 9 9 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability - 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans ' 1 6-301.12 Hand Drying Provision 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.00q: *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
{I
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Town of Barnstable Barnstable
Board of Health j e``��j
g" MASS, 200 Main Street, Hyannis MA 02601
2007
Office: 508-862-4644 Paul Canniff,D.M.D.
FAX: 508-790-6304 Junichi Sawayanagi
Donald Guadagnoli,M.D.
October 31, 2016
Mr. Arthur J. Luke
6 Narrows Lane
South Yarmouth, MA. 02664
RE: Variance.to Operate with One Restroom Facility;"
A.J. Luke's of 132, 1166 Iyanriough Road; Hyannis
Dear Mr. Luke,
You are granted a variance to utilize the existing toilet facility for the operation of a food
establishment at 1166 lyannough Road, Hyannis. The variance granted is as follows:
r
Section 322-4 Toilet Facilities: To utilize one restroom in lieu of the requirement
to provide separate male and female toilet facilities for male and female employees.
The variance is granted with the following conditions:
(1) This variance decision letter shall be posted on the wall adjacent to the food
permit in an area which is easily accessible to be read by a health inspector
anytime routine inspections are conducted.
(2) This variance is not transferable to anyone other than the applicant. In the event
that,this business is sold or transferred, both the owner of the building and the
licensee have the duty to inform any and all potential purchasers of the existence
of these variances and the fact the Board has explicitly made them non-
transferable.
This variance is granted because the applicant testified that the foundation is a cement
slab and it would not be feasible to install plumbing below the flooring due to the
excessive cost to do so. Also, there will be no more than three employees working at
this establishment during each work-shift. The Board is of the opinion that operation of
this establishment with one toilet facility for three employees should be sufficient.
m erely vai
\-..IV VILIr
Pa
Chairman
Board of Health
Town of Barnstable
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Board of Health
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Ej 200 Main Street,Hyannis MA 02601 � /
Office: 508-862-4644 Wayn A.MeHer,M.D.�/
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FAX: 508-790-6304 Junichi Sawayanagt
Paul J.Canniff,D.M.D.
VARIANCE REQUEST FORM
LOCATION
Property Address: ,J o � all
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--
Assessor's Map and Parcel Number: 7 Size of Lot: /
Wetlands Within 300 Ft. Yes Business Name: o i L oc, �� �
No Subdivision Name: l au 0
APPLICANT'S NAME: nf,)r �-- WICK Ph ne 1 7 q _o 3 Cr}
Did the owner of the property authorize you to represent him or her? Yes No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: t-C-C. Name: T� r
Ah
Address: 6, M ammo La Address: U'KkufbkLA U -1
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Phone: .—� 1�{- 2 �, — O P-9 J' Phone: -J-7�6p,3 f� d �-C 1 c� <� �
VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach' more space nee ed)
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NATURE OF WORK: House Addition ❑ House Renovon ❑ Repair of Failed Septic System ❑
Checklist (to be completed by office staff-person receiving variance request application)
Please submit copies in 4 separate completed sets.
_ Four(4)copies of the completed variance request form
_ Four(4)copies of engineered plan submitted(e.g.septic system plans)
_ Completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or registered sanitarian
_ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
_ Signed letter stating that the property owner authorized you to represent him/her for this request
_ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date,at applicant's expense (for Title
V and/or local sewage regulation variances only)
_ Full menu submitted(for grease trap variance requests only)
_ Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/lessee only],
outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the
building proposed])
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED Wayne Miller,Chairman
NOT APPROVED Junichi Sawayanagi
REASON FOR DISAPPROVAL Paul J.Canniff,D.M.D.
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Town of Barnstable
CIAS CHED. DATE;_
wlt Board of Health
W 200 Main Street, Hyannis MA 02601 j
Office: 508-862-4644 Wayn A,Miller,M.D.
FAX: 508-790-6304 Junichi Sawayana��—,�
Paul J.Canniff,D.M.D.
VARIANCE REQUEST FORM
LOCATION
Property Address: ( 6 Q2 �q c"`1 Q o y
Assessor's Map and Parcel Number: 0 0(12 Size of Lot:
Wetlands Within 300 Ft. Yes Business Name: . 3 a_ LAG
No Subdivisio&Name: ` L
APPLICANT'S NAME: rtf t) W ICZ Phone , 7 L 6 3 C`�
Did the owner of the property authorize you to represent him or her? Yes ✓ No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: �E�2 r 44� 1-. c-(± LCrC Name: Aa--7 tt-o r S- ' L4,o--
Address:��, /VOWS �►,l � � Address: (0 GJ E ('6Y
Phone: ") '��{- 2 �, - O P-9,s Phone: _-7 7q--6
VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach kpe-orespCe nee ed)
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NATURE OF WORK: House Addition El House RenovAon Repair of Failed Septic System C3
Checklist (to be completed by office staff-person receiving variance request application)
Please submit copies in 4 separate completed sets.
_ Four(4)copies of the completed variance request form
_ Four(4)copies of engineered plan submitted(e.g.septic system plans)
_ Completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or registered sanitarian
_ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
_ Signed letter stating that the property owner authorized you to represent him/her for this request
_ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title
V and/or local sewage regulation variances only)
_ Full menu submitted(for grease trap variance requests only)
_ Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/lessee only],
outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the
building proposed])
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED Wayne Miller,Chairman
NOT APPROVED Junichi Sawayanagi
REASON FOR DISAPPROVAL Paul J.Canniff,D.M.D.
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: C/
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2ppl cation for -isposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade V
Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. i t (e 0_,AV%GjC'� ( Owner's Name,Address,and Tel.No. t t u( 1�
Assessor's Map/Parcel �tutjt\i (A
Installer's Name,Address,and Tel.No. _ Designer's Name,Address,and Tel.N . UZbb I
0` 60k ��J ckrx
Type of Building: f�r�YLy 3 l2 4 S
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building L-A V-A&r No.of Persons INJl Showers( ) Cafeteria( )
Other Fixtures 11�3t(h-1_11
Design Flow(min.required) Y1 ► A gpd Design flow provided gpd
Plan Date rN i'--N Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore descri on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to plac a sy in oper n until a Certificate of
Compliance has been issued by this Boar ealt ,
Signed i Date
Application Approved by 9 61k%_�il.{� lid Date a/
Application Disapproved by Date
for the following reasons
Permit No. Q.0 — �j�QZZ Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
1-1 - - - ` ` has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
#bedrooms Approved design flow and
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
-----------`----------------------------------------------------------------------------------------------------------------------------
(7.0 � � .` V - _ __ __..._ __ _. ._.._-- ._...__. -_..-- ---- _ -- -----.. Fee - __�� . -- -- - - -
No. 7 `
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstrm (Construttion Permit
Permission is hereby granted.to Construct ) Repair( ) Upgrade( ) Abandon(VZ
System located at G i1J� �� i
L
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
C Date ��� ( Approved by