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WEQUAQUET LAKE CLUB - FOOD
WEQUAQUET LAKE CLUB 150 ANNABELLE PT.RD CENTERVILLE f ' rtKE BOARD OF HEALTH Town of Barnstable O John T. Norman Board of Health Donald A.Gaudagnoli,M.D. BARNSTABLE. F.P.(Thomas)Lee AS Daniel Luczkow,M.D. Alt. 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 175 Issue Date: 01/01/2022 DBA: WEQUAQUET LAKE YACHT CLUB OWNER: WEQUAQUET LAKE YACHT CLUB INC. Location of Establishment: 150 ANNABLE POINT ROAD CENTERVILLE MA 02632 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 150 OutdoorSeating: 0 Total Seating: 150 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent - I FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office Ilse Only, Initials: � Town of Barnstable Date Paid �$3ED— BAMSTABL4 Inspectional Services 1 Public Health Division check# Thomas McKean,Director L �. 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE ��[Lr.- NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: W f. Q U i Q tI ! k4ke A�i 6144 ADDRESS OF FOOD ESTABLISHMENT: 15-6) A JU u d h 0149 9,01 Al - k0-4 P `EPHAV% 0 j MAILING ADDRESS(IF DIFFERENT FROM ABOVE): P.O • Icy, 2&8 cEfeR V'Iff A owp--x E-MAIL ADDRESS: �� H b �(� ��Cen yiy wo • C�0 +yf TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (Rt 77G- 32 3 6 CS 4 v '-15-6 � TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO ✓ ... (ANNUAL WATER ANALYSIS REQUIRED)" ANNUAL: SEASONAL: 1,-' DATES OF OPERATION:k/ll/� 91/s/L=- NUMBER OF SEATS: INSIDE: 2Gir OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES... (MONTHLY LAB ANALYSIS REQUIRED) CATERING...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY* REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: // ��'I FULL NAME OF APPLICANT Gi r a V A f+�H au r lG f� SOLE OWNER: YESC D.O..iB OWNERPHONE#L54E) 774- 37-39 tV ADDRESS_ P�.�d 0?� Z�� • C �tF� tG��, AA 02tin CORPORATE OWNER: W`!JC � ZkC. CORPORATE ADDRESS: %So A A.wAti,e Afe rd PERSON IN CHARGE OF DAILY OPERATIONS:�i�l� JI�A'I�•kalE�.- `'G'� ' " y 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.sro' A U /1 1V / ?Z /Z'S 1. V 116M 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION* SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/appfications.asil. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec. 3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC lst. Q:\Application FormsTOODAPP REV3-2019.doc r - pF� t Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARN . Paul J.Canniff,D.M.D. �$ As k. 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: 175 Issue Date: 01/01/2021 DBA: WEQUAQUET LAKE YACHT CLUB OWNER: WEQUAQUET LAKE YACHT CLUB INC. Location of Establishment: 150 ANNABELLE POINT RD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 150 OutdoorSeating: 0 Total Seating: 150 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: -- -- - - — - MOBILE-FOOD: MOBILE-ICE CREAM: Q� _ FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: — PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: f opt For Offic Initials: do Town of Barnstable Date Paid t AII1LPs1$ BARNWABM Inspectional Services NAM Zq ' 9eb 039. ,0$ p,Ep39�. Public Health Division Check# Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 /APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE l�l u NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: VA UE7 �/�� yam'""� cluk ADDRESS OF FOOD ESTABLISHMENT: ��U ANA'Ab CAL& ?U'A,-F MAILING ADDRESS(IF DIFFERENT FROM ABOVE): p 0• "�>v X E-MAIL ADDRESS: uQ p v 4y �P Alt Lit 0 /, 4 0' , C6 Wt TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (job) -716, - 37-3f, TOTAL NUMBER OF BATHROOMS: 0- WELL WATER:YES NO ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: ✓ SEASONAL: DATES OF OPERATION: /l le-1 TO /Z / 3 NUMBER OF SEATS: INSIDE:2 S OUTSIDE: TOTAL: Z OS 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 TAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) "FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED& BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q\Application FormsTOODAPP 2020.doc IL G� �f OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/&�p D.O.B OWNER PHONE# Q 66) 7�� ADDRESS /t U Atilti.R('2,f1l1 P6 Stir�4k &k-f22Ll f t(r CORPORATE OWNER: 1reb`c�e -3(Ar> CORPORATE ADDRESS: pU•��� 2� Co Cx-hitu'.L(f, M oZ(�,3Z PERSON IN CHARGE OF DAILY OPERATIONS: ��� D 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. sc)"it /14uLt-&1 ! 2Z / 05 10 2. y SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openina!! 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 htt�://www.townofbarnstable.us/bealthdivision/applications.aspwww.townofbarnstable.us/bealthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.31'each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. QAApplication FonnsT00DAPP REV3-2019.doc MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include copies of your employees' food protection manager training certificates (at least two) and food allergen awareness training certificate (at least one.) In addition, please include the required fee amount (see fees at bottom of this page). Make check payable to: Town of Barnstable. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax copies of your employees' food protection manager training certificates (at least two) and food allergen awareness training certificate (at least one.) In addition, you must mail the required fee amount (see box below). Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. FEES: Bed &Breakfast Permit= $55; Food Service Permit 0-49 seats= $250; 50 or more seats $300; Continental Breakfast= $30; Retail Food (only TCS Foods)= $20; Retail Food Store—Less than 8,000 S.F. _ $100, more than 8,000 S.F. = $285; less than 1,000 S.F.; Retail Food Combo/Limited Prep. - $200.00; Cottage Food Industry= $75;Mobile Truck=$50;Mobile Ice Cream Truck= $35; Frozen Dessert License= $30; Additional non-refundable Fee for New Establishment or New Ownership=$100-$500(see staff), Late Fee = $10 Q:\Application Forms\FOODAPP REV3-2019.doc SHF BOARD OF HEALTH d � Town of Barnstable John T.Norman Board of Health Donald A.Gaudagnoli,M.D. PAMSTAOLF Paul J.Canniff,D.M.D. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 30513, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 175 Issue Date: 01/01/2020 DBA: WEQUAQUET LAKE YACHT CLUB OWNER: WEQUAQUET LAKE YACHT CLUB INC. Location of Establishment: 150 ANNABELLE POINT RD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 150 OutdoorSeating: 0 Total Seating: 150 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: A •' For Office Use Only: Initials: °f'"E'°'rti Town of Barnstable 'n Q` Date Paid i� Amt Pd$� IMMSTABLE. : Inspectional Services MARK Check# Z3 g cmfi , 'OfE1659.Dna�°�e� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A/FOOD ESTABLISHMENT DATE I JZ� NEW OWNERSHIP RENEWAL v NAME OF FOOD ESTABLISHMENT: LsF-QVAQVE7 tAh 6(,4 ADDRESS OF.FOOD ESTABLISHMENT: �SU A���II� PGf�f- IW• ■ `IE�+ � MAILING ADDRESS(IF DIFFERENT FROM ABOVE): P.6 . 1d%' Zl�p� !:�%�N��+t ���• G2�3Z E-MAIL ADDRESS: Jd"b pAL r6e%e. Ac41 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 45 776 - 3236 TOTAL NUMBER OF BATHROOMS: WELL WATER: YES_NOV ...,(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: ✓ DATES OF OPERATION:&/A I/A Iro 7 /ZG NUMBER OF SEATS: INSIDE:200 OUTSIDE: TOTAL: ZGb 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? --111 IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?� TYPE �O�F,�ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) �rO SERRV�IIC+E 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 (w S&VA'dt V t�r �IA'M�- / W4b SOLE OWNER: YES/� D.O.B OWNER PHONE# TT ADDRESS /50 AI&AbL L 901#. ' &L C1E utv CORPORATE OWNER: CORPORATE ADDRESS: sort' PERSON IN CHARGE OF DAILY OPERATIONS: 3r 6o ?Azk&%, 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 31blt/ 1. �bl G�k+• // t r / is 1. Sco* Au`lu. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/heaIthdivision/at)plications.asp. OUTDOOR COOKING:'Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.31s1 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Q;AAApplication FormsTOODAPP REV3-2019.doc I _ pErtl Town of Barnstable BOARD OF HEALTH Paul 1 Canniff,D.M.D. A.Ga Board of Health Donald A.Gaudagnoli,M.D. RARNSTAOM- John T. Norman MA F.P. Thomas Lee Alternate $ b3q. 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 175 Issue Date: 03/01/2019 DBA: WEQUAQUET LAKE YACHT CLUB OWNER: WEQUAQUET LAKE YACHT CLUB,INC. Location of Establishment: 150 ANNABELLE POINT RD CENTERVILLE MA 02632 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 150 OutdoorSeating: 0 Total Seating: 150 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - -- - -- - - - -_-- ------ MOBILE-FOOD: MOBILE-ICE CREAM: MCA FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE i Restrictions: r s - i r i E ' f pf'{NE Tp� I111t1a1S; � Town of Barnstable, Date Paid Amt Pd.$ * BARNSTABLE, • - ''� i MASS. �, Inspectional Services , K Qp 039. �� Check# f A'FOMa�A Public Health Division Thomas McKean, Director g t r 200 Main Street,Hyannis,MA 02601 �� � ��xJ Office; 509-862-4644 Fax: 508-790-6304 PPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT E DATE NEW OWNERSHIP RENEWAI'� NAME OF FOOD ESTABLISHMENT: r-bubaL cr ekb d ADDRESS OF.GOOD ESTABLISHMENT; � /"'/LA.4�e,�.� e MAILING ADDRESS(IF DIFFERENT FROM ABOVE): « s E-MAIL ADDRESS: e p v t7 p t lc es, TELEPHONE NUMBER OF FOOD ESTABLISHMENT:-( } - J ©��� TOTAL NUMBER OF BATHROOMS: c� WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:*" (TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. F ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST 13E APPROVED BY THE HEALTH DIV,AND L.ICENSING, AND MEET OUTSIDE DINING RE,QUIREMENTS. u IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? TS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? t ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY BELOW) TYPE or IJSTABL ( 0OD SERVICE 4 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 FOOL) ONLY REQUIRED'TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED f a Q:\Application Forms\C-'OODAPPRGV2018.doo I - � G a i g i t E PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT— ------- 5-M -77(-3z3� . SOLE OWNER: YES NO D.O.BOWNER PHONE# i ADDRESS n CORPORATE OWNER:IL �IT FEDERAL ID NO. : D G Cam: CORPORATE ADDRESS: Cot �6 E PERSON IN CHARGE OF DAILY OPERATIONS: S A ,tlEiv 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. E "ATTACH COPIES OF CERTIFICATES" The Health Div. will NOT use past years' records. You u must provide new copies and POST THE CERTIFICATES at your food establishment. t Certified Food Managers Expiration Date Allergen Awareness Expiration Date k `q ,Z( 1. E SIGNATURE OF APPLICANT DATE i 5 * kFOOD POLICY INFORMATION",' SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. Dior 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 ;F event. You must complete a catering notice found at http !/�vw�y towuofbarnstible,us/l�ealthdivfsion/a p�lications.asp. '3 F :W 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. i NOTICE: Permits run annually from January Istto Dec. 31",each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN ii THE COMPLETED A.PPLICATION(S)AND R-EQUMED FEES BY DEC 1 st, i Ir: Q:\j\pplication Corms\FOODAPPRrV2018.doc i THE rpk, TOWN OF BARNSTABLE HEALTF!INSPECTOR's Establishment Name: Date: Page;, of W OFFICE HOURS ° PUBLIC HEALTH DIVISION i BARNSTABLE. 200 MAIN STREET 3.30 4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MAss. �. MON.-FRI. HYANNIS,MA 02601 50a-asz asaa No Reference ;R;Red.Item PLEASE PRINT CLEARLY ., rpMAya, , `FOOD ESTABLISHMENT INSPECTION REPORT Name V (.NCI& Dat Ty of Type of Inspection I ))T� / Qoeration(s) Routine ( a ( I / Cc� Address 1 �� �. Risk a .c Re-inspection .' � � ( . Cevel . Previous In r Telephone Residential Kitchen , Dat Mobile a-opera r lion Owner HACCP Y/N Temporary �✓.Il � Caterer General Complaint Person in Charge(Pic) Time Bed&Breakfast HACCP In: Other - Inspector Out: 3S-�= i uu- k . 6r- [ .. • tar Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated, '.Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking, 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ ! - - Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ c FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands V' n �y I n vc SEX 6( ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities - EMPLOYEE HEALTH PROTECTION FROM CHEMICALS •. ❑ Reporting y p y C ❑ 14.Approved Food or Color Additives 2.Re ortin of Diseases b Food Em to ees and RI - ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE (AATIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) v V ❑4.Food and Water.from Approved Source ❑ 16.Cooking Temperatures Ct c ❑ 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 0�- II �Jd ❑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 Hand'washing CONSUMERADVISORY ❑ 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 - TO Ye Non-critical(N)violations must be corrected immediately or Overall Rating. �_- within 90 days as determined b the Board of Health. y y ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled `_❑ Emergency Suspension C N Official Order for Correction:Based on an inspection'today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑_Emergency Closure ❑ Voluntary Disposal ❑ Other:.: 23..Management and Personnel. (FC-2)(590.003) This report,when signed below by a Board of Health"member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical.violations, 24.F B=One critical violation and lessthan-Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 4von7critical 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 if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot 27.Physical_Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical: If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous orToxic Materials (FC-7 590.008 9 violation,4 to non- ritic I.violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. - - 30.Other DATE OF RE-INSPECTION: Inspector's Si atur Print: 31'.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's g Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N - _- --•--- +..- .:.--r,<r-. - _' �-t T. :s - :_ -.--v�.-- n:o_ �_- _ - a -- - _.. - - --< - ... ° -.- ,:r+.;�,�r„rt„'�t=::.._ -s.� -:t'_� _ s - _ '- .: •...a. - -- � --� _. _ - +_ - 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 3-50114(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* $ 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 s 2-103.11 Person-in-Chazge Duties Cooked and RTE Foods.* ? 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 590.004(F) 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* * 2 .590.003(C)--. Responsibility.of the.Person-in-ChargeOther*. 3-501.16(A) Hot PHFs Maintained At or Above 140°Fge[o 7402.11 Common Name-Working Containers* 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* * 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 1 ( ) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* 590.004 11 Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11' Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Resumed Food and AdulteReserrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 590.003(E) Removal of Exclusions and Restrictions .Disposition ofAdultereted or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A). Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual.Warewashin Hot Water 7.206.12 Rodent Bait,Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*' 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 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 Concentration and Hardness* 22 3-603.11 Consumer Advisory Pasted for Consumption of 3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* PP Y Not Otherwise Processed to Eliminate Equipment* ( )O Pathogens*590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * Effective inrzooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 316 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 7 SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A Violations of Section 590.009 A incater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) �) Vi ( ) Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-30111 Clean Condition-Hands and Arms*.Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under 929-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 * 3-301.12 Preventing Contamination When Tasting* 3 403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following the Food Code and 105 CMR 590.000 6 Tags/Records:Shellstock fo 8 sections v f 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70'F 3-202.18 Shellstock Identification* Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 1.003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 Supplied with Soap and hand Drying Devices 590.004(J) Labeling of Ingredients` 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures I 6-301.11 Handwashing Cleanser,Availability 28. 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* 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. HEALTH INSPECTOR'S Establishment Name: yV yQ �"�° li°�� L��/ Date: l f 1- 24 Page: / of oFtHEro�r TOWN OF BARNSTABLE 9 v tip rr y;,r4, r OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. = 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified V M1.67q• HYANNIS,MA 02601 508-808-8 -FRI.62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT Name Lip C" Date r jyge o Tvoe of Inspection / Routine Address l �Q� Risk Food Serve Re-inspectionAn Level Retail Previous Inspection Telephone Residential Kitchen Mobile Pr�-oe Owner HACCP Y/N Temporary Sus Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP /In: IC)'.10 � PYZV Other ae G{ �iLL( �� 140 L' Inspector Out: 10,3t) Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. „p Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ !�L 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) ❑ ,����„n� �� /� FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands v'Cal ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 14 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 D 0L ❑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 r t� ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories II�,V Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations ? Critical(C)violations marked must be corrected immediately. (blue&red items) i`/ �� Corrective Action Required: ❑ No El Yes Non-critical(N)violations must be corrected immediately or Overall Rating l 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 B=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 l than 9 non-critical. If no water,sewage 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must less an non-cr o c s g back-up,infestation of rodents or insects,or lack of be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Sig re Print, fQ 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N (t NO 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* $ Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 590.004(F) 7-101.1 1 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-IO2.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 3-302.11(A) Food Protection** 7-201.11 Separation-Storage* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 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) Removal of Exclusions and Restrictions 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Disposition ofAdulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* I 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 Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 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* 3-401.11 A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.1 I(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game * of d-t112mt 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* Pathogens 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* E 4-702.11 Frequency of Sanitization of Utensils and Food * 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* ggs 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 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* in mobile food,temporary and residential 10 Proper,Adequate Handwashing g• P Y Game and Wild Mushrooms A Arms* 3-401.11 C 3 Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Approved By ( )( )2-301.11 Clean Condition-Hands and A * Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to � 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All'Other PHFs-l45°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 17 Reheating for Hot Holding Good Hygienic Practices practices should be debited under k29-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 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23.30) 3-202.15 Package Integrity* g g 3-403.1I(C) Commercially Processed RTE Food-140°F 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 riskfactors listedabove,can 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 CMR 590.000 be found 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 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 3-402.]2 Records,Creation and Retention Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005 * 5-205.11 Accessibility,Operation and Maintenance * 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 6-301.11 Handwashing Cleanser,Availability 27.8. Physical Facility FC-7 007 7 Conformance with Approved Procedures/ g Y 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 00 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590FormbackE2doc *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. v/Sco°F THE r TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date: r Page: Of . W OFFICE HOURS C HEALTH AR E. PUB2 0 MAIN ST RETSION 3:30:30-4:30 P.M.-s:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. HYANNIS,MA 02601 MON.-FRI.sos-862-asaa No Reference R-Red Item PLEASE PRINT CLEARLY rFD MPS FOOD ESTAB ISHMENT INSPECTION REPORT - a Name I Date a of Type of Inspection Routine Address Risk < Food Serve a Re-inspection L vel `Re Previous Inspection Telephone , Residential Kitchen Mmness Mobile Owner HACCP Y/N Temporary Caterer General Complaint Person in Charge(PIC) VA Time Bed&Breakfast HACCP Other 121 Inspector Each violation checked requi!4 an explanation on the narrativ page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 4 1 1 &-:-/ ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities J 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 TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures low ❑ 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 LZ _( [) ❑ 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ g Y ❑ Voluritary Disposal . ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 9 re ardless of the number of critical,results in an F. (FC 4)(590.005) cited in this report may result in suspension or revocation of the food 25.Equipment and Utensils B=One critical violation and less than 4 non-critical violations 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 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 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-critical violations. If 1 critical refrigeration. 29.Special.Requirements (590:009) within 10 days of receipt of this order. violation,4 to 8 non-critical vi latio s=C. 30.Other DATE OF RE-INSPECTION: In o s Signature Q Pr t 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N _fJJ/// #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Si a Pnn• Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Screen Dumpster ? 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* L 8 Cross-contamination L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to * 7-102.11 Common Name-Working Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201:11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* 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 * Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water 3-401.11A(1)(2) Eggs- mme s sec Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145`F 15 sec* Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg enve 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces ofP 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 of Equipment* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical*- g 590.009(A)-(D) Violations of Section temporary and a ide in cater- * Ratites-165°F 15 sec* in mobile food,tem or and residential Sources 10 Proper,Adequate Handwashing - g' P Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whale-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )(b) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practiceRequirements.sshould 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* 3-403.11 C * (Blue Items 23-30) 3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140*F Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-2,03.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient. 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. WQp IME Tow TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: -(. lPage: ofOJL OFFICEHOURSPUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNIMABLE. • 200 MAIN STREET O 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. $, MON.-FRI. ,639. HYANNIS,MA 02601 508-862-4644 No Reference R Red Item - PLEASE PRINT CLEARLY pTFD M p FOO ESTABLI HM INSP - TI REPORT Name hP Date e o Type of Inspection e I Routine Address Ij- Risk Food Se Re-inspection 04- "Level tali, Previous Inspection Telephone VAVResidential Kitchen D i Mobile re-o era r Owner HACCP Y/N Temporary spect Illness NOW J Caterer General Complaint Person in Charge(PIN PI ) tfh. O Time Bed&Breakfast HACCP ® A Other Inspector Qe, 8ut: J I Each violation checked requires an explanation on the narrativ pages)and a citation of specific provisions)violated. h /' 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) ❑ C 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 ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) 14 A_ n - ' ❑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 t PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control t ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) f r ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP (�y ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories o Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Q, Critical(C)violations marked must be corrected immediately. (blue&red items) J Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined b the Board of Health. Overall Rating ry p ❑ ❑ p ❑ Y y ❑ Voluntary Compliance Employee Restriction/Exclusion Re-inspection Scheduled Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ 23.Management and Personnel (FC-2)(590.003) Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 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 B=One critical violation and less than 4von-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 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 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-critical violati ns. If 1 critical refrigeration. violation,4 to 8 non-critical violati s= ' 29.Special Requirements (590.009) within 10 days of receipt of this order. p 30.Other DATE OF RE-INSPECTION: Ins or's j O 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y IN #Seats Observed Frozen Dessert Machines: Outside Dining Y N P 's Signatur Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N a Dumpster Screen? Y N 2�L f� }'sue- 1 - r't - _ L, _ °�` . • . 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) I Assignment of Responsibility* S Cross-contamination 1q 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 * 590.004(F) ( )O P 7-101.11 Identifying Information-Original Containers * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 590.003(C) Responsibility of the Person-in-Charge[0 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F Applicants* 3-302.11(A)' Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control ` 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 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)tB)Resumed 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 Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(1-)) 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. 1 g Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F I5 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking.Water from an Approved System * gg Not Otherwise Processed to Eliminate Equipment ( )( ) Pathogens*590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g *_Effective 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency 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 StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan_Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* 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 * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* Blue Items 23-30) 3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodbome 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* L18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70'F 3-203.18 Shellstock Identification ( ) Item Good Retail practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590,004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. 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. No. �VU =_y Fep 0 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppfiraction for Migonl bpotem Con5tructfon Permit Application for a Permit to Construct( . )Repair( X)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. e U 0 Owner's Name,Address and Tel.No. 7 7 5-0 5 4 3 1 "0(d, Centerville Wequaquet Lake Yacht Club Assessor's ap/P cel Camp Opechee Rd, Centerville � Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic PO Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft: Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install -a 1500 g a l H 2 O grease trap. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provisions of Title 5 of the Env'ronmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by th' and Health. Signed Date Application Approved by Dated =v 3- Application Disapproved for the following reasons Permit No. '�Uu3 - y S Date Issued �. Y 1� `_i s - � "�,� .., ',`� `r � � ��. a� �` '�ti_ f..`, `. ��{ f , �.� �. �'i �� r �� . "'F b... �f 3� F 4� �� i"" 4 � � 2 ff�� 41f` 'i4� �7 ti I � i:'� �� No. l)IJSTW7 Fee 1 O O.O 0�. t Entered in computer: 1/ 1 THE COMMONWEALTH OF MASSACHUSETTS Yes `PUBLIC',HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application fors Migpozal bpttem conztruction permit Application for a Permit to Construct( )Repair( ,_�Upgrrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. n A 2 U 0` Owner's Name,Address and Tel.No. — d, Centerville Wequaquet Lake Yacht Club Assessor's Map/Pazcel a 1 I r 01 S =Centerville Camp Opechee Rd, Centerville Installer's Name,Address,and Tel.No. 775-87762 Designer's Name,Address and Tel.No. `-Wm E Robinson Sr Septic .r,,P � Box 1089, Centerville = Type of Building: „ Dwelling, No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons - Showers,( ) Cafeteria( ) Other Fixtures 1 Design Flow gallons per day. Calculated daily flow } gallons. Plan Date Number of sheets Revision Date . 1 Title i Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a 1 500 gal H2O grease. trap. ; , Date last inspected: ' `f h, Agreement: -"-The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Eny' onmental C de and not to place the system in operation until a Certi i- . i cate of Compliance has been issued y this d o ealth. Signed. Date Application Approved by r DateS- Applkation Disapproved for the following reasons 1 Y Permit No. a U,U s- t/ S�� Date Issued -------------- - i THE COMMONWEALTH OF,MASSACHUSETTS WLYC BARNSTABLE, MASSACHUSETTS (Certificate of Cow'fiance THIS IS TO CERTIFY, that the On-site Sewage Disposa4System Constructed ( )Repaired( X)Upgraded( ) Aband ed by Wm E Robinson Sr Septic.r(Service oac�; enter i e SU,_� N� a as been constructed in accordance at _ with the provisions of Title 5 and the for Disposal System Construction Permit No. 2Ou S ' YSSated 7 Installer Designer The issuance of this pe t shallnot be construed as a guarantee thatC&e system l ion a i nos 'd ` Date �� .� Inspec �"'----__ - WLYC THE COMMONWEALTH OF MASSkOHUSETTS PUBLIC HEALTH DIVISION - BARN STAB LE},MASSACHUSETTS i ` i Mi5po5ar *pZtem Construction Permit Permission is hereby granted to Construct( )Repair( %ntirville Upgrade t( )Abandon System located at • de Road, /�7�✓� � /���,. `fit i- '` :► and as described in the above Application for Disposal System Construction Permit. T he a plicant,recognizes his/her duty to comply with Title 5 and the following local provisions or special,conditions. Provided:Construction must be completed within three years of the date of this rp it. R ff\ Q Date:��_ �- v Approved b1 �", y`- TOWN OF OF BAnRN�STABLE LOCATION _ /S12 Ann-,ble l'o,.�¢ �l�( SEWAGE # VILLAGE CPA krv! iL ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. i�aa.>E, �Mf�a Set'l iL _A;t Sad 77J�Tjy SEPTIC TANK CAPACITY _ �.5�iD C�a�Io�., G Gse �CatP LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMrrDATE: %b i-Or COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility). Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I � ' (� Se Trap 5-1 I V No..-1..P�Z.� Lo�. F>s...�,5_2.... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Allpfiratinn for Binpuna1 Workii Tomitrn.rtiun frrutit Application is hereby made for a Permit to+Construct ( ) or Repair ( �an Individual Sewage Disposal System at• .... .. ='--\ ......... .........•----------•------•--.......------ ---------.........-•------..........-•---- Q Locat n-Address or Lot No. ._ .......� L .... �--�-'.. �!..1. ... ........� \\\\ _ .. . ....... � Installer �ddress Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )►� `4 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures ............................ . W Design Flow............................................gallons per person per day. Total daily flow........._..................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth............... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ,_� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit.No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ .......................:...... ` .............................._._._..._.............._�._._......................._.--...__......_............. Description of Soil__�ye. P�-_�'xi�Q. .Yfi... .. W��� �. N ._��1' `ti?_...!^R1 x --------------------- - 1 ...............................----------------------------------------------- ---------------------------'•-•-------•-- U Nature of Repairs or Alterations—Answer when p linable.-_1���k. ...........is .....�-�......r ... ts �-- ---------------------------------------- --------------------------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the , system in operation until a Certificate of Comp ' ued by the board of health. Signed ...--- -- -- .... . .. .- Sf ........... ....... ------.......... Date ..:'Z Application Approved B Date PP PP Y Application Disapproved for the fo owing reasons: ...... ------------ --------------------- ---------------------------------............................. ----------------------------------------- .. Date PermitNo. -...�t)....-... ........................ Issued --- -------------------. ............................----------- Dace di Y&N. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF.BARNSTABLE Apfiration for Rapasal Varks Chun inn Frnnit Application is hereby made for a Pe,,M Construct or Repair an Individual Sewage Disposal CC S y or Iat No. ——-------------------------------- ------------------- Installer Address Type of Building Size Lot----Sq. feet Dwelling—No. of Bedrooms----------------------------------------Expansion Attic Garbage Grinder Other—Type of Building ---------------------------- No. of persons---------------------------- Showers Cafeteria Pao Otherfixtures --------------------------------------------------------------------------------------------------------- Design Flow------------------------------------------gallons per person per day. Total daily flow-------------------- Septic Tank—Liquid-capacity------------gallons Length----------------Width_------------------------------- Diameter----------------Depth--- Disposal Trench—No--------------------- Width-------------------Total Length--------------___Total leaching area_-----------sq.ft Seepage Pit No--------------------- Diameter-------------------- Depth below inlet------------------Total leaching area-----------.sq. ft. z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by------------------------------------------------—---------------------- Date_---_ Test Pit No. I________________minutes per inch Depth of Test Pit-_--_____________-_ Depth to ground water---------------------- 44 Test Pit No. 2----------------minutes per inch Depth of Test Pit_---_---.__-______- Depth to ground water--_-----___-__-___-__<Z� '� VNA I J---- ----—-----—-----/N 0 Description of Soil-- ----- --------------------------------------------------------T ----------------- U ---------------------- -------- ------- ------- ------------------------------------------------------------------------ --------------......-- -------------------------------------------------------------------------- u _aL------- ----------- 15 0 Nature-of R WkN�' --------b------ -------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental—The undersigned further agrees not to place the system in operation until a Certificate of Compl ed by the board of health. I (q Signed_�-- ------------------------------------------------------------------------------------------------- ------ 16 ApplicationApproved By -------------------)�a--- ------------------------------------------------------------------- -------------------------- 1).w Application Disapproved for the follouning reasons: -------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- D" 9'*n___._5 ----------------------- Pern No- ----- g!s ---- -------- Issued ------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tlertifirz& of ;9mytinure Sewage Disposal System c tructed or Repaired bi , I e'-N ---------------- -------------- Z�� at ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of Abe State.Environmental Code as described in the application for Disposal Works Construction Permit No- ----------y--- --- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------- ?-__�_ ---------------- Inspector --- ------------------------------------------------------------------------------- ----------------------- ----------- -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......................... FzL------ Map fttsVl�d - tt Vrrmit Permission is hereby granted--------------------------------------------------- --------------------------------------------------- S 1 ��. \ ------ --------- to Constru gor&Regr TML Spq Ukl k , I"di -dual r D Sal * t at No.... ---------- Street as shown on the application for Disposal Works Construction Permit No-_-__-----`_____ Dated----------------------------------------_ -!d of -----------------------------------B�U Health DATE------------- ............................. FORM 38308 HOBBS&WARREN.INC.PUBLISHERS ' ',. :. L6 r It it ' t , t : Q S• : r � i I - r - �. g r TOWN OF BARNSTABLE LOCATION [50D SEWAGE # V1.LLAGE ASSESSOR'S MAP 6z LOT4 J) ' 611_ • I _ INSTALLER'S NAME & PHONE NO. < �� SEPTIC TANK CAPACITY _I LEACHING FACILITY:(type),FJVX- (.size) 3 u NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER i BUILDER OR OWNER LNQ.1_h.o i DATE PERMIT ISSUED: Q DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No A:7 IF7 5 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA`02108 (617).292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor CommissionerSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION Property Address: e Name of Owner Address of Owner VAQWf - Date of Inspection:. Name of Inspector:(Please Print) ��� 1 am a DEP approv system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Mailing Address: Telephone Number: 1 CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se ge disposal systems. The system: _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Is �-- Inspector's Signature: — Date: ( q The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board,of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Jti �r revised 9/2/98 Pagel of11 %4?Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or A A. SYSTEM PASSES: V I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: D Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ND Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPUER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER i revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either"Yes" or "No" to each of the following: �l)U I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. ✓ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet.but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes"or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 Y 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done:You must indicate either "Yes" or"No" as to each of the following: Yes No / Pumping information was provided by the owner,occupant,or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. / The system does not receive non-sanitary or industrial waste flow. f ✓ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 0 5.302(3)(b)1 V _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms(design):_ Number of bedrooms(actual):_ Total DESIGN flow Number of current residents:_ Garbage grinder lyes or no):_ Laundry(separate system) (yes or no):_; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):_ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no):_ Last date of occupancy: COMMERCIALIINDUSTRIAL:Type of establishment: AMP Ca-6eL r i,�n�� Design flow: 62 S gpd ( Base n 15.203) �� �A^'� ° R''Y�^(dy 3 x iso= SJ 514 Basis of design flow M4uk Grease trap present: ye or no) Industrial Waste Holding Tank present: (yes or no)�JU Non-sanitary waste discharged to the Title 5 system: (yes or no)�O Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Q8:21 CAMV Mess A00ic.ld.:;ti Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection:(yes or no)_ If yes,volume pumped: gallons Reason for pumping: TYPE 9FSYSTEM l/ 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) I/A Technology etc.Attach gopy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: (ly Sewage odors detected when arriving at the site: (yes or no) A)O revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:_cast iron IZ140 PVC—other(explain) Distance from private water supply well or suction line kU W Diameter Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) u Depth below grade: Material of construction:_/concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) GREASE TRAP• OS (locate on site plan) Depth below grade:_ 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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or 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/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries,number. leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) CESSPOOLS-_ (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(cesspool must be pumped as part of inspection) 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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 4. A_ � f -63 p revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater_Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record i Observed Site(Abutting property,observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 Z,-548 659 760 Receipt for Certified Mail e No Insurance Coverage Provided UKMD Do not use for Interria'ional Mail Pow� (See Reverse) _ Sant to Of St n t � P fate and &CodeCr Pos e Co)CIO Certified Fee O Special Delivery Fee a Ri ee,6-d Ihe`11Vdgr'/Fee RetIlVA,RL&ceiitt StidVO n"§t tS Wl&rW&Date Delivered Return Receipt Showing to Whom, Date,and Addressee's Address TOTAL Postage &Fees Postmark or Date I � STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). a 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address In leaving the receipt attached and present the article at a post office service window or hand it to j your rural carrier(no extra charge). Ic {6 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return C0 address of the article,date,detach and retain the receipt,and mail the article. 3. If you want a return receipt,write the certified mail number and your name and address on a r return receipt card,Form 3811,and attach it to the front of the article by means of the gummed co ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. O M 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, M endorse RESTRICTED DELIVERY on the front of the article. 0 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If el return receipt is requested,check the applicable blocks in item 1 of Form 3811. d 6. Save this receipt and present it if you make inquiry. 105603-93-e-0216 d SENDER: ■Complete items 1 and/or 2 for additional services. I also wish t0 receive the H ■Complete items 3,4a,and 4b. following services(for an h ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ai ■Attach this form to the front of the mailpiece,or on the back if space does not 1. El Addressee's Address 4) permit. ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery <n ■The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. °- o v 3.Article Addressed to: 4a.Article Number d ( /' 7— W 7 E f� 4b.Service Type u ❑ Registered Certified Cn N 9-0 �(> `. I%- p Express Mail ❑ Insured cc w Retum Receipt for Merchandise ❑ COD Date of Delivery ° z G ''a >- 5.Received By:(Print Name) .Addressee's Address(Only if requested and fee is paid) X 6.Signature: (Addressee orAgent)'Q H PS;Form 381:1;'December 1994 i _: € Domestic Return Receipt i i4 !itt !ilili{ ij ii tt1 ( ; First-Class Mail UNITED STATES POSTAL SERVICE Postage&Fees Paid USPS Permit No.G-10 4 • Print your name, address, and ZIP Code in this box• �TME, os Town of Barnstable F Department of Health, Safety, and Environmental Services r BAMSTABM MASS. Public Health Division FDN10�� P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health 'a December 3, 1998 Joseph Cordeiro, Jr. Manager 90 Whip-O-Will Drive Hyannis, MA 02601 Dear Mr. Cordeiro, The Board of Health Regulation entitled"Onsite Sewage Systems/Change of Use Cause to Inspect" listed as Part VIII, Section 4.00 specifically states: "no person shall change the ` use of an existing building from seasonal to year-round unless the on-site disposal system has the capacity to properly dispose of sewage generated by year-round use and unless the building confirms to minimum standards of fitness for human habitation." The septic system at 150 Annable Point Road must be inspected by a DEP certified septic system inspector prior to the change of use. Attached is a listing of certified inspectors available to conduct such an inspection. .The inspector must also determine the capacity of the septic system. Please ensure that you comply with the Board of Health Regulation by having the septic system inspected and by having its capacity determined on or before January 15, 1999. Sincerely yours Thomas McKean, R.S. Director of Public Health Enclosure: List of Certified Septic System Inspectors q/cordeiro/ks Search far Map/Parcel 211015 Fo`t' BUslfleSSPIa e.' ,Phoney ��o alp rlls .. Ferrn�tf1�o 2005455 ,_ , lel Pe, x` 1 09/15/20051 Issuance a#e. Gom le#tonr Dafe 09/29/20051 Pp� £ Size of.Se tIC Tank �� 1500 gallon h 20 grease trap robinson mappar ' 211015 ((r�irer WEQUAQUET LAKE YACHT CLUB ; p[oe 150 ANNABLE POINT ROAD lfi4 T�rpe. R.VA SeJrv-,- � u se - .._