HomeMy WebLinkAboutHYANNIS MOBIL SERVICE - RETAIL FOOD ODO F
HYANNIS MOBIL SERVICE
1449 IYANOUGH RD. ,HY.
► � Town of Barnstable
BOARD OF HEALTH
John T.Norman
7} Board of Health Donald A.Guadagnoli,M.D.
BAR.NWABM « F.P.(Thomas)Lee
"A Wn, Daniel Luczkow,Alternate
x� � w 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: 534 Issue Date: 1/1/2021
DBA: HYANNIS MOBIL SERVICE
OWNER: HYANNIS MOBIL INC.
Location of Establishment: 1449 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
Q
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
For Office Initials: 9
�►�, Town of Barnstable t
Date Paid Amt Pd
> aTAB z Inspectional Services
MAM.
Public Health Division >
TtrD.MA't
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT PERMIT APPLICATION(Non Flavored)
DATE /1 1L� NEW BUSINESS OWNERSHIP RENEWAL K
NAME OF TOBACCO ESTABLISHMENT:
ADDRESS OF TOBACCO ESTABLISHMENT:
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: lel
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: Llia
OWNER'S NAME: '6C6Aje OWNER'S PH#aq) t3�
OWNER'S ADDRESS: //� ������d� C�/���`�� Zd, � j �
CORPORATE NAME: 4W 4-At/4)/ 1�
;
CORPORATE ADDRESS: /'-�y/��t/i?//S CORPORATE
ANNUAL:/ SEASONAL: DATES OF OPERATION:_/_/ TO / /
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)..
TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS:
a,
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/33996392 a
MA GENERAL LAW CHAPTER 270/SECTION 6:
https•//male�islature Gov/Laws/GeneralLawsi?artlV/Titlel/Chaoer270/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
I ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: /
1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document
2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 ✓
SIGNATURE: .
PRINTED NAME: ` DATE:
Q:1Application FormsITOBACCO APP-NonFavor 12-18-19.docx
. 5
a?
i
d
ESTABLISHMENT'S NAME
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of
the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the
penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section
371-9. of the Town of Barnstable Board of Health Regulation:
Sales to Minors— 371-9. Sale and Distribution of Tobacco Products.
1. No person shall sell or provide a tobacco product, as defined herein,to a person under
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
i
2. Identification: Each person selling or distributing tobacco products,as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of t
Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws:
a
Signature Printed Name Date
Si Printed Name to
Signatur Printed Name Date
S gnature rinted Name Date
Signature Printed Name Date
X
y
Signature Printed Name Date h
Signature Printed Name Date
Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.doex
11/3/2020 MassTaxConnect
_
-C<
......: a
Confirmation Welc=omc,RICHAR D FALVEY Settlnc;s
Home Cigarette License Tobacco License Form Confirmation
Contact Us Frequently Asked Questions Video Tutorials
• Tobacco License Form(account level)-Confirmation
License Renewal Confirmation 0-475 029-056
Number:
Renewal Fee Amount Due: $50.00
Renewal Period: "30-Sep-2022
Payment Amount: $50.00
Payment Effective Date: 03-Nov-2020
Submitted Date and Time: 11/3/2020 8:58:45 AM
Taxpayer Name: HYANNIS MOBIL,INC.
Account ID: CGL-10286219-003
Your license renewal and payment have been filed successfully.You will receive emails shortly containing the above confirmation numbers and other det�
Please print this page and save the confirmation number above for your records.
•---'— --- - ��* ,'�' ¢„ �, � $ may �,�'""' `� s�"� a�at
Y r
k ::&
0012-11067703 TAXPAY° 20277
Form '941 for 2020: Employers QUARTERLY Federal Tax Retum 950120
(Rev.July 2020) Department of the Treasury--Internal Revenue Service OMB No. 1545-0029
EEEK Report for . „
Employer identification number(EIN) one.)
Name(not your trade name) HYANNIS MOBIL INC ❑ 1:January,February,March
Trade name(if any) ❑ 2:April,May,June
Address 1449 ROUTE 132 ❑X 3:July,August,September
Number Street Suite or room number ❑ 4:October,November,December
Go to www.irs.gov1Form941 for
HYANNIS MA 02601 instructions and the latest information.
city State ZIP code
Foreign country name Foreign provincelcounty Foreign postal code
Read the separate instructions before you complete Form 941. Type or print within the boxes.
Answer these questions for this quarter.
1 Number of employees who received wages,tips,or other compensation for the pay period
including:Sept. 12(Quarter 3)or Dec. 12(Quarter 4) 1 4
2 Wages,tips,and other compensation . . . . . . . . . . . . 2 43,960.00
3 Federal income tax withheld from wages,tips,and other compensation. . . . . . . . . . . 3 5,660.28
4 If no wages,tips,and other compensation are subject to social security or Medicare tax ❑ Check and go tQ line 6.
Column 1 Column 2
5a Taxable social security wages L 439760,070 x 0.124= 5,451,074
5a (i) Qualified sick leave wages. . . . x 0.062=
5a (ii)Qualified family leave wages. . . ---�x 0.062=
5b Taxable social security tips . . . x 0.124= --�
5c Taxable Medicare wages 8r tips 43,960.00 x 0.029= 1,274.84
5d Taxable wages Sr tips subject to
Additional Medicare Tax withholding x 0.009=
5e Total social security and Medicare taxes.Add Column 2 from lines 5a,5a(i),5a(ii),5b,5c,and 5d 5el 6,72&88
5f Section 3121(q)Notice and Demand—Tax due on unreported tips(see instructions) 5fl
6 Total taxes before adjustments.Add lines 3,5e,and 5f . . . . . . . 6 12 386.16
7 Current quarter's adjustment for fractions of cents . . . 7
8 Current quarter's adjustment for sick pay . . . . . . . . . . 8
9 Current quarter's adjustments for tips and group-term life insurance 9
10 Total taxes after adjustments.Combine lines 6 through 9 . . . . . . . . . 101 12 386.16
11 a Qualified small business payroll tax credit for increasing research activities.Attach Form 8974 11 a
11 b Nonrefundable portion of credit for qualified sick and family leave wages from Worksheet 1 11 b
11c Nonrefundable portion of employee retention credit from Worksheet 1 . . . . . . . . . . . 11c�—
► You MUST complete all three pages of Form 941 and SIGN it.
For Privacy Act and Paperwork Reduction Act Notice,see the back of the Payment Voucher. Cat.No. 17001 Z Form 941 (Rev.7-2020)
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
BARNsrABL :` Paul J.Canniff,D.M.D.
MASS F.P. Thomas Lee Alternate
z 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: 534 Issue Date: 1/1/2020
DBA: HYANNIS MOBIL SERVICE
OWNER: RICHARD D. FALVEY
Location of Establishment: 1449 IYANNOUGH ROAD HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2020
TOBACCO SALES: $85.00
Permit Expires: 12/31/2020
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
.. .. .___.......... .. . ....... ..._. ...... ............_. .__. . . .. .
Town of Barnstable For Of. Initials:
Inspectional ServicesMAM
Amt Pd$
�� Public Health Division 1
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT PERMIT APPLICATION on-Flavored
DATE NEW BUSINESS OWNERSHIP RENEWAL
NAME OF TOBACCO ESTABLISHMENT:
ADDRESS OF TOBACCO ESTABLISHMENT: t �J. ,�1 S vim:�i 64 60J
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): __...
E-MAIL ADDRESS: /U 1 _.
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT:
OWNER'S NAME:. e. ' !� OWNER'S PH# -
OWNER'S ADDRESS.
CORPORATE NAME:
CORPORATE ADDRESS:/ CORPORATE
ANNUAL: SEASONAL: DATES OF OPERATION: /_/ TO
DAYS CLOSED EXCLUDING HOLIDAYS(EX. MONDAYS):
TOWN OF BARNSTABLE COMMA.GENERAL LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/3,3996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
https://malegislature. ov/Laws/GeneralLaws/PartIV/`TitleI/Chapter270/Section6
***NEW BUSINESSES AND NEW OWNERS ONLY***
REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED.
PLEASE CALL 508-375-6621
ALL APPLICANTS ARE REQUIRED TO SUBMIT.THE FOLLOWING REQUIRED DOCUMENTS:
1) MA State License to Sell Cigarettes d 3) IRS Federal Tax ID#Document
2) MA State License to Sell Cigars and Smoking Tobacco / 4) Payment of Fee(s) -see page 4
SIGNATURE:
PRINTED NAME: C DATE:,
Q:1Application FormATOBACCO APP-NonFavor 12-18-19.docx
/ESTABLISHMENT'S NAME
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of
the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the
penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section
371-9. of the Town of Barnstable Board of Health Regulation:
Sales to Minors—1371 9. Sale and Distribution..of Tobacco Products...
1. No person shall sell or provide a tobacco product, as defined herein,to a person under
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
2. Identification: Each person selling or distributing tobacco products,as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of
Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws:
Signature Printed Name Date ,
Al- 5LjeA-
Id.
$i Printed Name Date
r
Signa Printed Name Date
e Printed Name Date
Signature Printed Name Date
Signature Printed Name Date
Signature Printed Name ::Date
Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx
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r� .1# BOARD OF HEALTH
Town of Barnstable
Paul 1 Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
i BM%NS`ABM John T.Norman
MIAs' F.P. Thomas Lee Alternate
200 Main Street, Hyannis, MA 02601
+fig ' a Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 534 Issue Date: 12/20/18
DBA: HYANNIS MOBIL SERVICE
OWNER: RICHARD D. FALVEY
Location of Establishment: 1449 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: an
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:
� I
Town of Barnstable
Inspectional Services
`" & Public Health Division
1639.
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
August 13, 2018
Mr. Falvey;
I am the permit technician from the Town of Barnstable. I am handling the tobacco and the retail
permits for your establishment. We've noticed that there has not been a payment or applications for
these permits since 2013. We need to have you apply for 2017/2018 permits and pay for each of those
years. We will forgive the previous years for you. The tobacco permit with the town is$85.00 per year
for a total of$170.00 and the retail permit for selling candy, gum and soda is$20.00 per year. The total
for 2017/2018 would be $40.00. There is a $10.00 late fee for each year and the total late fee is$20.00.
We will need one check made payable to Town of Barnstable for$230.00. Please be aware these
permits run on the calendar year and you will receive new applications for 2019 at the end of this year.
We will need you to complete the enclosed applications. The tobacco forms need to be signed by all
employees that will be selling tobacco products. If you have any questions, please let me know.
Sincerely;
Dianna M. Bellaire
Town of Barnstable
200 Main Street, Hyannis MA 02601
508-862-4643, email:dianna.bellaire@town.barnstable.ma.us
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
�RT►Fj
Important: A. General Information o
When filling out I (04�,
forms on thecomputer,use1. Inspector: q� .�only the tab key ip
to move your CHRISTIAN A ZAHNER IV q�+Sy�
cursor-do not Name of Inspector
use the return
key. BAYSTATE SEWAGE DISPOSAL, INC.
Company Name
r� 105 KINGMAN ST
Company Address
LAKEVILLE MA ,02347 r
City/Town State Zip Code
508-947-2636 S13606 ,n
Telephone Number License Number '
B. Certification
I certify that I have personally inspected the sewage disposal system.at this address and that the °
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Fu er Evaluation by the Local Approving Authority
07/08/10
ate r0he
eystem inspecto shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP._The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurfacesal m Pa nf 17
i
Y' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N FIND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N FIND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE #11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is MA 02601 07/08/10
required for HYANNIS i
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: GAS STATION / RETAIL
Design flow(based on 310 CMR 15.203): UNKNOWN-NO PLANS
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
ISLANDS/SQ.FT.
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available: N/A
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENT
Date
Other(describe below):
General Information
Pumping Records:
Source of information: UNKNOWN
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
UNKNOWN-NO PLANS AT BOARD OF HEALTH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 12"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: TOWN
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
JOINTS ARE GOOD. VENTING IS GOOD. NO EVIDENCE OF LEAKAGE.
Septic Tank(locate on site plan):
6"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8'X 4'X 4'
Sludge depth:
6"
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
L v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE #11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? TAPE MEASURE
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
INLET AND OUTLET TEES ARE IN PLACE. LIQUID LEVEL IS RIGHT AT THE OUTLET INVERT.
TANK APPEARS TO BE WATERTIGHT AND STRUCTURALLY SOUND.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 10 of 17
-Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
11
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-BOX IS LEVEL AND EQUAL. NORMAL SOLIDS CARRYOVER. D-BOX APPEARS TO BE
WATERRTIGHT AND STRUCTURALLY SOUND.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE #11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SOIL IS SANDY. NO SIGNS OF HYDRAULIC FAILURE, PONDING, OR DAMP SOIL. NO
VEGETATION.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
V
3Z-►
v
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
•Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1449 ROUTE 132
Property Address
MOBIL HYANNIS- BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >8
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
NO PLANS AVAILABLE
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
THERE WERE NO PLANS AVAILABLE AT THE BOARD OF HEALTH. THERE IS NO SIGNS OF
ANY GROUNDWATER PRESENT IN THE LEACHING PIT. PIT IS AT A LOW LEVEL WITH NO
SIGNS OF BEING HIGHER.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
•Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1449 ROUTE 132
Property Address
MOBIL HYANNIS-BARNSTABLE#11730
Owner Owner's Name
information is required for HYANNIS MA 02601 07/08/10
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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