HomeMy WebLinkAboutCHAKULATI CHOCOLATES - FOOD - CLOSED - -- - - 0 59 "IS - -
_7 fOGD
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
LCRNMBIX • Paul J.Canniff,D.M.D.
o a , 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: 1090 Issue Date: 12/10/2019
DBA: CHUKULATI CHOCOLATES
OWNER: LIANA STRIDER
Location of Establishment: 3821 FALMOUTH ROAD/UNIT 3A MARSTONS MILLS, MA 02648
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
s
For Office,UsC 0 Initials:
Town of Barnstable Date Paid i Ib Amt I'd$ ✓ F
ea i e.
Inspectional Services
MASS. � p�,
Public Health Division
Thomas McKean, Director MA
a-:
200 Main Street,Hyannis,MA 02601 Eti
Office: 508-862-4644 Fax: 508-790-6304 y`'
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE M- R NEW OWNERSHIP�4 RENEWAL
�\q--
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT:
MAILING ADDRESS(IF DIFFERENT FROM ABOVE)::
E-MAIL ADDRESS:
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS:
WELL WATER:/YES NO_'4 ... (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)
4,-OOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL.MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q\Application FormsTOODAPP 2020.doc
OWNER INFORMATION:
FULL NAME OF APPLICANT_ Q pp
SOLE OWNER:% D.O.B�`L 5 J OWNER PHONE# �fl 9-0 �®
ADDRESS,24�.C,t ¢�,� ®17Ti� 'C�� l��I�C 1?3 U&S-COA�l t als Mk rOW1
CORPORATE OWNER: N
CORPORATE ADDRESS: /
PERSON IN CHARGE OF DAILY OPERATIONS:
List(2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
1. t��,� ��� �'�- t0� t� ��0221. ��A�� 5���� . ► � �� �20��
SIG ,APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
vrrior 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/annlications.asi).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Apphcation FormsTOODAPP REV3-2019.doc
oF111HE rok TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: / Date: Page: 1 of
�y` ~o OFFICE HOURS TT---
PUBLIC HEALTH DIVISION 8:00=9:30A.M.
BARNSTABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION D/e Verified
e3q: HYANNIS,MA 02601 More.-FRi. No Reference R-Red Item PLEASE PRINT CLEARLY
�iOTFD MA'S - 508-862�644
FOO ESTABLISHMENT INSP C ION REPORT
Name Date`31 T e o 4104amspection
n Routir
Address I Risk [1 V Food Service Re-inspect" n
l vel Re Previo n pe o
Telephone Residential Kitchen Date:
Mobile Pre-oper i `
Owner HACCP Y/N Temporary Suspect II s i
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
k Other
InspectorAM
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 I
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 17
❑ 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 j�
:�p
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations`v
Critical(C)violations marked must be corrected immediately. (blue&red items) V J-1 cx`^�V. Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the Nites ❑ 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 B=One critical violation and less than 4non-critical violations g
(FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 oVvi,,Iations.
cal. 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
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-crif a If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
v ,4 to 8 non-critical viol ' ns
30.Other DATE OF RE-INSPECTION: In tor's i atu e /
31.Dumpster screened from public viewr I
All
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N 111
#Seats Observed Frozen Dessert Machines: Outside Dining Y N C's Signature Prin.
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 4
3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 6 Cross-contamination 14 _ . Food or Color Additives ; Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* - * .19 PHF Hot and Cold Holding
' 2-103.11 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) * - . .
*
2 590.003(C) Responsibility of the Person-in-Charge Common Name-Working Containers*
3-501.16(A) Hot PHFs Maintained At or Above 140 F
�Require Reporting by Food Employees and Contamination from the Environment
7-201.11 Separation-Storage* 3-501.16(A) Roasts Held At or Above 130°F
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits
Restriction-Presence and Use*its 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
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* ,, REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rated or 7-204.12 Chemicals for Washing of Food* Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
y 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 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
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* Effe c"°e utrzo°i
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.1 l(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Chemical 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.
* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )( )
11 Good Hygienic Practices practices should be debited under#29-Special
3-201.17 Game Animals* y9 17 Reheating for Hot Holding 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
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30)
12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
13 Handwashin Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification* 9 ( )
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F[0 41°F/45°F Item Good Retail Practices FC 590.000
5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
Tags/Records:Fish Products P 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient
* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients" Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
"Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
oFT T 'TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: \ Y Date: Page: of
v c OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. = 200 MAIN STREET 3.30-a.3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
7 AqS• HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item. PLEASE PRINT CLEARLY
�`rEc s 508-862-4644
FOCIChESTABLISHMENTINSPOCTION REPORT
AA fr' G 4 x^
Name Date Type o 'qnsoection, ^
p 1 outin
Address Risk ood Servid7 n4petinLevel Previ Telephone 0 Residential Kitchen- Date:Mobile Pre-onOwner HACCP Y/N Temporary Suspss
LA
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
Other -
InspectorP M: I
Each violation checked requires an explanation on the narrative pag (s)and a citation of specific provision(s)violated. - ' / V
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) ❑ A
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
Oq
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)
n9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items ® 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 4 non -crib violations
if no critical violations observed,4 to 6Hocncal 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. . f 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 anon-cri
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address non-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to 8Hon-critical violatio s=C.
29.Special Requirements (590.009) -
30.Other DATE OF RE-INSPECTION: Inspe for Signatur Print:
31.Dum ster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N -
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature 1 apl�
Print: o
Self Service Wait Service Provided Grease Trap Size, Variance Letter Posted Y IN
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)
*
2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F
7-102.11 Common Name-Working Containers
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
Storage*
-
Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* * Raw Seed Sprouts Not Served*
Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I jMonitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
* 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
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff°"°e uusoor
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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and 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 practiceRequirements.
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* * (Blue Items 23-30)
3-202.15 Package Integrity* g g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
4.11 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* 5-20
* 5-20 .11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils
3-402.12 Records,Creation and Retention 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 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I 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.
oFIKE rok TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of '
. qo 11HEA OFFICE HOURS
BARNSTABLE. P 62 0 MAN STREEETSION - 3::300--4:30 A.M.:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
e3
`0$ HYANNIS,MA 02601 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
�p 508-88-862�644
'FON1"' FOOD ESTABLISHMENT INSPECTION REPORT C )
Name Date Tvoe of T section
O era ' utin
Address Risk Sery - pection
Level I 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 L4
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 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 I r ?
❑ 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) 6 _
❑ 4.Food and Water from Approved Source ❑ 16.Cooking Temperatures a8
❑ 5.Receiving/Condition ❑ 17.Reheating r.
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP _
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories h+J%►
Violations Related to Good Retail Practices(Blue Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations ^!
Critical(C)violations marked must be corrected immediately. (blue&red items) ` Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items ❑ 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 25.Equipment and Utensils (FC-4 regardless of the number of critical,results in an F.
590.005 6=One critical violation and less than 4non-critical violations 9
)( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
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
28:Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to a noncritical violations. if 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to Snon-critical violations=C.
29.Special Requirements (590.009 Y P -.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dum ter screened from public view
Permit Posted r Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' Si ur
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N � v ��
Dumpster Screen? Y N
.. � ... ° , . .* • rX ,.. nr. .,�.. _ems:. a v • w.
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 7-101.11 Identifying Information-Original Containers*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 590.004(F) - • *
2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
7-102.11 Common Name-Working Containers
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
3-302.11(A) Food Protection*
Applicants* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
590.003(E) I Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
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
4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a Hermetical) Sealed Container* : Raw Seed Sprouts Not Served*
y Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
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* Effective rnrzom
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*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
aces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
3-201.15 Molluscan Shellfish from NSSP Listed . Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Chemical *
Sources* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing Ratites-165°F 15 sec 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-Han Arms*
Hands and A * ( )( ) p
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
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
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 TagsiRecords: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 - Handwashin g Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F[0 70°F
3-203.12 Shellstock Identification Maintained* y
Convenientl 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
3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*- i
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.
I
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� r Town of Barnstable BOARD OF HEALTH
Paul J Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
[�{otzatuae John T.Norman
MA F.P. Lee Alternate
0. ,� 200 Main Street, Hyannis, MA 02601 Thomas
�rac" 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: 1090 Issue Date: 12/20/18
DBA: CHUKULATI CHOCOLATES
OWNER: LIANA STRIDER
Location of Establishment: 3821 FALMOUTH ROAD/UNIT 3A,MARSTONS MILLS MA 02648
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
_ FEES
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: -- - - - - - - ------ — — -
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
i
FIKE rok, For Office Use Only: Initials:
Town of Barnstable =;5
Date Paid Amt Pd$
BAMSTABU. Inspectional Services
�. $
9� 1659• 1
AlEOA Public Health Division Check# 1=Lat
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304 42
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: N 0 rU LAon NX O Coi w� r
ADDRESS OF FOOD ESTABLISHMENT: -9 1 FAU-t V t H Wn-`kTA
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): O-I0KV USA 0&Kmt'. (.p1;1 b2�
E-MAIL ADDRESS: 1
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: Cris aL--6c—
TOTAL NUMBER OF BATHROOMS: t `
WELL WATER: YES NO V/... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION:/f All/1j TO iZ/ -g1/ t q
NUMBER OF SEATS: INSIDE: O OUTSIDE: O TOTAL: .a
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING
REQUIREMENTS.IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? I�t O
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? NO
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL,MOBILE &NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
Q:\Application FormsTOODAPPREV2018.doc
PLEASE CALL 508-862-4644
OWNER INFORMATION: +ern, ,!�
FULL NAME OF APPLICANT L�/n' 0A S 1 I UG 1�
SOLE OWNE YES NO D.O.B 6 OWNER PHONE# !!j , fj�b— 1S1O
ADDRESS f
CORPORATE OWNER: FEDERAL ID NO. :
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS: L i ANA M I DV
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
y
1. I-I A t4A CID I fl . i 16 2 1. ULNA Sf'l l i 11 i 23
2. b3 /20 / ?.t,
SIG APPLI T 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.
TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1 st to Dec. 3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
QAApplication FormsT00DAPPREV2018.doc
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Pro o a Menu
Pre- Packai?ed Foods for Retail Foods Made-To-Order Foods Made-To-Go
Single-Origin Organic Chukulati Bars Sipping Chocolate Raw Organic Fruit Tartlets
(organic cacao mass,organic cacao butter,organic Using one of our Single-Province Arriba Nacional Flourless Cacao Base
cane sugar,non-gmo soy lecithin) Cacao,infused with spices and herbs.Mixed into Cashew Cream
An array of assorted bars with complementary your choice of our in-house made almond milk, Berry Cacao
inclusions added(Nuts,dried fruits,seeds,spices, coconut milk,or water. 8 oz.1 12 oz. etc.
essential oils)or enjoy with only our ethically single-
origin premium chocolate. Drinking Chocolate Mocchi
Our house blend brewed to perfection warm and ganache or ice cream filled
Organic Chukulati Bars ready to go.
Using house blends to create a more specialty bar 8 oz 1 12 oz.1 16 oz. Fresh Truffles and Bonbons
Organic Inner-gy Bars Horchata/Colada Chocolate Dipped Fruit Pops
Raw Energy Bars
Protein Bar Made Fresh daily 8 oz.1 12 oz.1 16 oz. fresh fruit enrobed and topped
Super food Bar
Toast n'Spread Superfood Mendiants
Boxed Pralines& BonBons Spiced Avocado
Organic Raw Honey Pralines Chocolate Spread Ganache Macaroons
Organic Nut Gianduja Pralines Peanut Butter Banana
Seasonal Bonbons
Smoothie/Fondue Fruit Bowl Mousse/Tiramisu/Parfait
Bagged Chukulati Coated With a choice of an energizing smoothie base,or
Goods& Mixes with a rich chocolate fondue.Topped and Baked Goods
Nut&Fruit Mixes garnished with nutrient dense raw foods and fresh Fudge Chocolate Cake
Drinking Chocolate fruit. Brownies
Spiced Chocolate sauces Cookies
Authentic Cocada Custom Chocolate Bar Biscotti
Bagged Chukulati Topped with your favorites,just how you like it.
Cups and other confections 3 bars 16 bars
Brownies
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3821 Falmouth Road septic flows 1/4/2017
Summary by Down Cape Engineering, Inc. EXISTING
Building# Use First floor SF FF flow 2nd fir SF 2nd Floor Flow Existing Total Flow
1 Animal Hospital 1306 434.0 904 66.3 500.3
2 Aztec Repro (mixed)' 1026 7.7.5 780 58.5 136.0
3 Tanning/Office 1156 72.3 1156 86.7 159.0
4 Office/mixed 2199 275.0 1320 99.0 374.0
5 Quick Stop (retail) 1391 70.0 1391 104.3 174.3
6 Pak Mail (retail) 1890 95.0 1890 141.7 236.7
7 Windmill (retail) 1154 132.0 1154 87.0 219.0
9 Office 1158 87.0 1158 87.0 174.0
10 Office . 1070 80.0 1070 80.0 160.0
11 Office 899 67.0 899 67.0 134.0
Total: 1389.8 GPD Total: 877.5 Total: 2267.3 GPD
Note:Animal hospital is changing from kennels to office visits,from 50gpd/kennel to 75 gpd/1000 sf.
Site is not within a Zone II. All second floor spaces currently office use
PROPOSED: No kennels in Bldg 1 and replace office with two 1 bedroom dwelling units on 1st and 2nd floors of Bldg 9
PROPOSED 1
Building# Use First floor SF FF flow 2nd fir SF 2nd Floor Flow Proposed Total Flow
1 Animal Hospital 1306 97.5 904 66.3 163.8
2 Aztec Repro (mixed) 1026 77.5 780 58.5 136.0
�/A f 3 Tanning/Office 1156 72.3 1156 86.7 159.0 Cj
4 Office/mixed 2199 275.0 1320 99.0 374.0
NO
'' �.5 1391 104.3 174.3
Quick Stop (retail) 1391 70.0
6 ' Pak Mail (retail) 1890 95.0 1890 1 6.7 lv-1
7 Windmill (retail) 1154 "132.0 1154 87.0 219.0
yCP-1 9 Residential 1158 220.0 1158 440.0
10 Office 1070 80.0 1070 80.0 160.0
11 Office 899 67.0 899 67.0 134.0
Total: 1186.3 GPD Total: 1010.5 Total: 2196.8 GPD V
A
JCE#512 -Windmill Square, 3821 Falmouth Road, Marstons Mills, MA Date: 12-4-14
Summary of Wastewater Flows (LANDCOURT LOTS 1 & 2)
Existing Proposed
Building Description Flow d Description Flow(qpd)
1 Animal Hospital 500 Animal Hospital 300
2 Aztec Repo. 136 Aztec Repo. 136
3 Tanning, Office, etc. 160 Tanning, Office, etc. 160
4 Dunkin Donuts 459 Dunkin Donuts 385
5 Quick Stop 174 Quick Stop 174
6 Pak Mail 236 Pak Mail 236
7 Windmill 219 Windmill 219
8 Bank . 291 Dunkin Donuts 565
9 Office 174 Office 174
10 Office 161 Office 161
11 Office 135 Office 135
Total = 2,645 gpd Total = 2,645 gpd
Total Wastewater Flow for LANDCOURT LOT 1 = 565 gpd
Total Wastewater Flow for LANDCOURT LOT 2 = 2,080 gpd
Total Wastewater Flow for LANDCOURT LOTS 1 & 2 = 2,645 gpd
3821 Falmouth Road septic flows 1/4/2017
Summary by Down Cape Engineering, Inc. EXISTING
Building# Use First floor SF FF flow 2nd flr SF 2nd Floor Flow Existing Total Flow
1 Animal Hospital 1306 434.0 904 66.3 500.3
2 Aztec Repro (mixed) 1026 7.7.5 780 58.5 136.0
3 Tanning/Office 1156 72.3 1156 86.7 159.0
4 Office/mixed 2199 27S.0 1320 99.0 374.0
5 Quick Stop (retail) 1391 70.0 1391 104.3 174.3
6 Pak Mail (retail) 1890 95.0 1890 141.7 236.7
7 Windmill (retail) 1154 132.0 1154 87.0 219.0
9 Office 1158 87.0 1158 87.0 174.0
10 Office 1070 80.0 1070 80.0 160.0
11 Office 899 67.0 899 67.0 134.0
Total: 1389.8 GPD Total: 877.5 Total: 2267.3 GPD
Note:Animal hospital is changing from kennels to office visits, from 50gpd/kennel to 75 gpd/1000 sf.
Site is not within a Zone II. All second floor spaces currently office use
PROPOSED: No kennels in Bldg 1 and replace office with two 1 bedroom dwelling units on 1st and 2nd floors of Bldg 9
PROPOSED
Building# Use First floor SF FF flow 2nd flr SF 2nd Floor Flow Proposed Total Flow
1 Animal Hospital 1306 97.5 904 66.3 163.8
2 Aztec Repro (mixed) 1026 77.5 780 58.5 136.0
3 Tanning/Office 1156 72.3 1156 86.7 159.0
4 Office/mixed 2199 275.0 1320 99.0 374.0
5 Quick Stop (retail) 1391 70.0 1391 104.3 174.3
6 Pak Mail (retail) 1890 95.0 1890 141.7 236.7
7 Windmill (retail) 1154 ".32.0 1154 87.0 219.0
9 Residential 1158 220.0 1158 220.0 440.0
10 Office 1070 80.0 1070 80.0 160.0
11 Office 899 67.0 899 67.0 134.0
Total: 1186.3 GPD Total: 1010.5 Total: 2196.8 GPD
5/11/2021 ShowAsbuilt(1700x2200)
TOWN OF BARNSTABLE
LOCATION 3fa_4 rkLovh..tS'14—ilq 1 SEWAGE#
` VILLAGE LUYV.4'(ASSESSOR'S MAP&/PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY (czb .ti(, �(Z;�ty(j� ������ ,�. •
LEACHING FACILITY:(Type) i�int�4t— (size) •) x H 173X�42
Ns'�'8F.88DB96Ms,I>r�i'��r
OWNER.Let.L—( r`Q4i(alcrNl�N��G�L�TQ ti'�,4�fA Lri'(Cr►1'i
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ..J- Feet
Private Water Supply Well and Leaching Facility(If any wells exist an
site or within 200 feet of leaching facility) Feet
Edge of Wctland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY ,r/. Fo1 yiy.7
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https://itsgIdb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=057004&sq=2 1/1
McKenzie, Marybeth
From: McKean, Thomas
Sent: Tuesday, November 21, 2017 9:39 AM
To: McKenzie, Marybeth
Subject: RE: New Chocolate facility in Centerville (old Lollicakes)
Thank you Marybeth.
Bathrooms cannot be shared with another business unless:
-the applicant requests a variance/permission from the Board in writing;
-the restrooms will be open at the same time the business is open.
From: McKenzie, Marybeth
Sent: Tuesday, November 21, 2017 9:14 AM
To: McKean, Thomas
Subject: New Chocolate facility in Centerville (old Lollicakes)
Tom,
Chukaulati is the new chocolate retail/food establishment going into the old Lollicakes. Quick question.They have one
bathroom in the basement the second one was capped off at some point, they didn't do it, but there are 2 bathrooms
that are in the common hall.They are used by Quick Mart and the Chukaulati place was told that they would be using
them too. Would that be Ok if they share the bathrooms and just have the one in the basement or should they put the
fixtures back in the bathroom that was capped off?They will not be having any seats. Please advise and thanks. Mb
1
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OU T E (L.O.VARIES) 28
r'r-s"vm EDGE OF PAVEMENT
386' — — — — — —
. —
PROPOSED 4-IN SCH 40 SEWER PIPE. \
• SLOPE 1%MIN (TYP )
PROPOSED H-20 1500 GALLON SEPTIC TANK _
INVERT IN EL.=94.00' `) f
-tNHOLE
PROPOSED SEWER MA
EXISTING EDGE OF PAVEMENT w � � ,INVERT OUT EL.=96.50'
EXISTING EPTIC LEACH PIT TO BE PUMPED WYE_1YPECONNECTION
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'} — SEPTICTANK '. ,.> a � + _'` / /N�
® a _E .O U T E (L.O.VARIES) 28 5
EDGE OF PAVEMENT
PROPOSED 4-IN SCH. 40 SEWER PIPE
PROPOSED H-20 1500 GALLON SEPTIC TANK SLOPE 1% MIN. (TYP.)
/ INVERT IN EL.=94.00'
N At) �1
PROPOSED SEWI
EXISTING EDGE OF PAVEMENT '
I'M OBSERVATION EXISTING SEPTIC LEACH PIT TO BE PUMPED INVERT OUT EL.=
WYE-TYPE CONNECTION (TYP.)
iydrant Spindle AND FILLED WITH CLEAN SAND (TYP. OF 5) _
aev. = 104.89' WELL = :_..
kssumed l
/ _ p CATCHBASIN
RIM EL.=99.81,CD
J
01P
100.1 O O INV. OUT _
EL.-97. 9's /—EXISTING 1000-GAL.
ROPOSED H-20 2000 GALLON PUMP -- i GREASE TRAP => ='
=< EXISTING 1500-GAL.
CHAMBER INVERT IN EL.=93.75' == ` (CONTRACTOR TO = O
� x� - �'�-��-"-- O O TANK (CONTRACTOI
EXISTING 1500-GAL. SEPTIC 0 . VERIFY)
TANK (CONTRACTOR TO INV. OUT EL.= 98.48' VERIFY) INV. OUT El
SB/DH MAP 57 +� _ _ v _ �: - - -
FND N
1 EXISTING 1500-GAL. SEPTIC
--';�1 -- TANK (CONTRACTOR TO
PARCEL 3 N ❑ r VVERIFY) INV. OUT EL.= 97.61'± _-- e
LOT 2 ' W
BLD 5 I
09,
TP2 1 BLD 4 1 BLD 6 100.7
W +� DUNKIN' DONUTS TOF=102.17' TOI
\ N (459 GPD) TOF=101.93' QUIK STOP PAK MAIL
/� PROPOSED 80'BY 20' 10•5 20.0' (174 GPD) (236 GPD)
PRESSURE-DOSED _ 36.5' TOF=102.03'
O DISPOSAL FIELD � _ _ � _: =• 9 \
10
TP 1 9yA_: : \ > MAP 57
100.60 =_` :.//t CONNECTION INVERT EL.=96.85 m
EXISTING LEACHING 4: 30 2,
PARCEL 4
°' PIT AND SPOILED ==. ;. BLD 9 '
SOIL TO BE ' - I �'ys�`� 108,109 S.F.±
OFFICE
OFFSITE
REMOVED o - :• - � BLD 3
(174 GPD)
°D TANNING, / m
PERFORATED
Z PVC PIPE +� _ ,, f OFFICE, ETC TO F= TOF=101.95' ri'G�s
(160 GPD) l 101.63' _-- —
I CB/DH ._f % - EXISTING 1500-GAL.
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