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HomeMy WebLinkAboutCENTERVILLE FOOD MART - FOOD (2) Centerville Food Mart 1149 Falmouth Road ' _�Centerville Vq-Iiz) bey i NEW OWNERS 2020 I BOARD OF HEALTH �Frt' x Town of Barnstable John T. Norman Board of Health Donald A.Gaudagnoli,M.D. RAWNSrhrsce F.P.(Thomas)Lee,. w� MAS& .� 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. 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: 188 Issue Date: 01/01/2022 DBA: CENTERVILLE FOOD MART OWNER: S. K. MART INC. Location of Establishment: 1149 FALMOUTH ROAD CENTERVILLE„ MA 02632 Type of Business Permit: RETAIL WITH FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r i !y ' f For Office Us.-Only. Initials: .�`"E'°' .� Town of Barnstable Date Paid (0 Amtpd$ Inspectional Services• ,nuvsrwu E i I f &I Public Health Division Check# 1 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 Ad %Z—ZI NEW OWNERSHIP RENEWAL NAME OF FOOb ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: W,//7,7a�K17%, D /�I MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: �r�w!/IGL�/1LG�� 1>/�'I�%�' �' �� %I�.�i�`� Ce1w ' �X TELEPHONE NUMBER OF FOOD ESTABLISHMENT: �� 77`y - 7L/,5 V` TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO_j/...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: ✓ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: X_ 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?_,Q _ IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? 00.j D TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE %--f 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 FonnsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT _5 SOLE OWNER: YES/NO OWNER PHONE ADDRESS Z, c/ , ZL v�l�i�n�t` .Dl� iOr✓ �h � T 04 CORPORATE OWNER: 4 S CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I 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 ri 2. NATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at htti)://www.townofbarnstable.us/healthdivisioti/applications.8s]). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January I st to Dec.3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc HEALTH INSPECTOR'S Establishment Name: Date: Page:,.- of °p THE f TOWN OF BARNSTABLE ..,, .... . .....,_, ._ - 9._._. ,. OFFICE°H(jURS -� PUBLIC HEALTH DIVISION 600•9.30A.M. BARNSTABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified mAss.639 �0 HYANNIS, MA 02601 soa MON.-FRI.-862-4644 No Reference R-Red-Item PLEASE PRINT CLEARLY.. FOOD ESTABLISHMENT.INSPECTION REPORT �- Name7, ►"1W� Date i r Type of Tvne of Inspection Address L � -Risk- ood Servi P Re-Ins ection Level Re a1 Previous spection TelephoneVAAA 'If Residential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary. Suspect Illness / --) Caterer General Complaint Person in Char9e(PIC) Time Bed&Breakfast HACCP J �� In: Other ...Inspector • Out: . J 46 Each violation checked.re uir s an explanation on the narrative page(s)and a citation of specificprovision(s)violated. - 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) ❑ L /� I J Action as determined by the Board of Health. Allergen-Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT - ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable,/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM.CHEMICALS _ �� ( CD• ❑-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) Ij ❑4.Foodand Water from Approved Source ❑ 16.Cooking Temperatures Y ❑ 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 7-S 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 ttQ� ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories L VD Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations c� - , Critical(C)violations marked must be corrected immediately. (blue&red items +� t] / ' ff .. � � � � Corrective Action Required: ❑ No _ ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance._, ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency.Closure ❑ Voluntary Disposal ❑ Other: - checked_indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more,than 3 non-critical violations. F=3 or more critical violations..`9.or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations _ regardless of the number of critical,results in an F. 25.Equipment and Utensils (FG 4)(590.005) cited.in this report may result in suspension or revocation of the food B-One critical violation and less than 4 non-critical violations 9 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to-6pop-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have aright 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;orlack 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 obsery to on-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to non-c itical Violations C. 29.Special Requirements (590.009) y P - 30.Other DATE OF RE-INSPECTION: Inspector' S`nature Pri t: 31.Dumpster screened from public view C ' Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's 1 nature Print: Self Service Wait Service Provided Grease,Trap Size• Variance_Letter Posted . Y., N ,.. Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contaminatton 14 Food or Color Additives Law Cooled to 41°F/45°F Withiri 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.* Additives* 19 PHF Hot and Cold Holding Aa .- 2-103.11 Person-in-Charge Duties 3-302.14 Protection from'Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C). Responsibility of the Person-in-Charge to Other*,. , ,; , . , ,; * 3-501.16(A) Hot PHFs Maintained At or Above 140°E - 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 * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils `590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g � ) Disposition of Adulterated or Contaminated' Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Roden[Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* y Pe 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective/nnoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source. 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs "SPECIAL'REQUIREMENtS'� �� ::x.�f = 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A).(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. * 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms ( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g. g g 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 foodbome 12 Prevention of Contamination from Hands 3-403.11 E Remaining 3-101.11 Food Safe and Unadulterated* ( ) g Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs 8 Tags/Records:Shellstock .Pe 9 following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Idenaficadon* 3-501.14 y3 Handwashing Facilities Cooling Cooked PHFs from 140°F to 70°F (A) g 3-203.12 .Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F •item Good Retail Practices FC 590.000 Tags/Records:fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 - .003 5-20411 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 3402.12 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 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 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. pp THE Tp TOWN OF BARNSTABLE - H oLF ICE PECTOR,s Establishment Name: Date: � Page: � � of OURS 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 MASS. $. MON.-FRI. �p 1659•A,0 HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT Name 1�7 Date Tyne of Type of Inspection �� � g Routine / Address _ /_ Risk = Level Retail ction Telephone Residential Kitchen Date: r /, Mobile Pre-operation Ci Owner HACCP Y/N Temporary Suspect Illness Caterer I General Complaint Person in Charge(PIC) b Time Bed&Breakfast HACC In: � er Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. e f Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS y ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives �ez, ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items] Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating a/ within 90 days as determined by the Board of Health. A ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Emergency Closure El Voluntary Disposal Other: ❑ 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils B=One critical violation and less than 4non-critical violations 9 (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations obs 7 to 8non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address = 29.Special Requirements (590.009) within 10 days of receipt of this order. violation, o 8 non- ritical violations C. 30.Other DATE OF RE-INSPECTION: Inspector's ig ture - 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 S' n Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N -..-1.r... ��-.-. _., ..-� /' •'c-�.r•Z-.�.��`... -s."ti-�.'.--_ "i..:•r....-+-v ti -. ..�. ,r.....�{`-+^L. ..._.+t .. --._�--- -�- t.�... .�.-...---s .r r ,-_.s.-,Y'^. .l - .ter' ..- - _ 'l_;--...� __.._�..�...�,y_, - `:'r".v• T--w. .z _ - _ . 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* 6 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding, ,. 2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15, Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each I 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other*. 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Y Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage*g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* Requirements 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) - Variance Re q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* - REQUIREMENTS FOR 3-306.14(A)(B)Resumed Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4- Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155'F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff.care mizooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155'17 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* Sources on g ou 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- * Proper,Adequate Handwashing g'Ratites-165°F 15 sec* in mobile food,temporaryand residential 10 Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145`F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165`F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-40L11(A)(1)(b) All Other PHFs-145 Other 590.009 violations relating to good retail °F 15 sec* 11 Good Hygienic Practices practices should be debited under#29-Special 3-201.17 Game Animals* 17 Reheating for Hot Holding 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g, g g 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 foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A Conlin Cooked PHFs from 140'F to 70'F 3-202.18 Shellstock Identification ( ) g P25. Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70`F to 41'F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45'F Equipment and Utensils FC-4 .005 5-205.11 Accessibility,Operation and Maintenance *3-402.12 Records,Creation and Retention* Within 4 Hours Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 1 Hand Drying Provision 129. 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:590Fofmback6-2doc *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. pF THE fp p TOWN OF BARNSTABLE - " OLFTH FICEHOURSR,s Establishment Name: Date: Page: - ! of [_ . P� PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30 430 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 9qp 6;9.' �.� HYANNIS, MA 02601 506-62-46" No Reference R. Red Item PLEASE PRINT CLEARLY ,FOMP,a. FOOD ESTABLISHMENT INSPECTION REPORT o Name ! Dated ;3 Tvue of T f Inspection p outine J Address (� Risk Food Servi Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint rryn�p� Person in Charge(PIC) Time Bed&Breakfast HACCP I Y titi `J 14 In: Other (-- Inspector ff� Out: ;. g- Each violation checked r quires an explanation on the narrative page(s)and a citation of specific provision(s)violated. 6 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) ❑ ?j _r -5-3 �h Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ b °v FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands l ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS OD Ct-( / � l 4-7 ❑ 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/Coridition ❑ 17.Reheating S' D C S? ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling / ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding A 14 PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control Dp '� � 0 co ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) L/v`�� be VT VV4A4- ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP n SY ( � rL, ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories kt&4ffD �e 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 Non-critical(N)violations must be corrected immediately or ❑ '` , - within 90 days as determined by the Board of Health. Overall Rating F ❑ Voluntary Compliance Com ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ m 90 Other: Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. Emergency Closure Voluntary Disposal ❑ 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 6=One critical violation and less than 4non-critical violations 9 (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 n -critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. :Inspector" Sign re PrintC30.Other DATE OF RE-INSPECTION: `/ 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 Sign Print: Self Service Wait Service Provided Grease Trap_Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 - Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection froin Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) * 2 590.003(C) Responsibility of the Person-in-Charge Common Name-Working Containers*ge to Other* 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* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* _� 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food. 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* i Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 _ Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.]IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11 A Clild Fd C Surfaces of * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* ( ) ean Utenss an oo ontact Eggs-Immediate Service 145°F IS sec Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef ct1w 1112001 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-1 1 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155 155°F IS sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 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 Requirements. radicsshould 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* 3-003.11 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 foodborne * 12 Prevention of Contamination from Hands 3-403.11 E 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 3-203.12 Shellstock Identification ( ) P25. Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices Physical Facility FC-67 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 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. Op VE rpk, TOWN OF BARN.STABLE .- .HEATH INSPECTOR'S Establishment Name: -- Date: _ Page: �- of. ti OFFICE HOURS AR E.O PUBLIC 2 0 MAIN STREET --- 3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 330-4:30P.M. MASS. g MON.-FRI. °lF,39. HYANNIS,MA 02601 sos-s62-4r No Reference R=Red Item. PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT Name Date f 3 L e o Jy4Waf Inspection _ tl 3 p outine Address Risk Food Se Re-inspection ` Level Retail Previous Inspection Telephone Residential Kitchen Date: -Q/ _ JA� Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness 3 � C bj Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP �/ s1- t ✓� In: �/t� Other O �✓ Inspector Out:'I" .J 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) ❑ ilc FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ,,/ ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures C- 42,4 ❑ 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 F ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories �� f u-'A 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. ❑ Y . 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 fl Win Schedu ed Lj Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal the 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 6=One critical violation and less than 4non-critical violations 9 (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9non-critical. If no critical water,sewage back-up, infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address vi , to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Insp tor's Signature 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 PI gnature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter.Posted -Y N Dumpster Screen? Y N .ram-...-.. _--..�. y".^.-.�^-w._.-r....1-.,...-� ,-..=,-i:..._�,.-r+,...+...._�^--�.v,....:.-s,,.�_,-...�...-"*-•,,...�� �.�--....,�.,--.,...-r.-._�.,.-_.. .�...._.. _ ... ....�-�, r� .. ..1.•.:.. -. - "__�. - +„ ..-.��_�•y - an--- _- ..� -.._ �.r-..`_. --. •�- ._ .. _:s-.. a ...._. ..- - .-s-^----_ 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) [Demonstrationof signment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) 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.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 75 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 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* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 1307-102.11 °F* Storage*- Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation 7-202.11 Restriction-Presence and Use* 20 Time as a Public Health Control 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 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* (11) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of 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 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Equipment 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 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff"r;'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 rf 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 1 p 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 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. g Receiving/Condition g, g g 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 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 3-50L14 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 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 1 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. TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: 'Le FT?C1 ! dVC Date: l 1 2,- (Page: of 1_ -OFFICE HOURS PUBLIC HEALTH DIVISION 800-9s0A.M. BARNSTABLE. ` 200 MAIN STREET s so-a:so P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified e19: `0� HYANNIS,MA 02601 M- -FRI. No Reference R-.Red Item PLEASE PRINT CLEARLY prFO MAC - 508862�1644 FOOD ESTABLISHMENT INSPECTION REPORT Name Ij ( Date 3 -Type o Tyoe of Inspection g) Routine �� �� ��-�/t ✓ V Address 1 I 1 I mil/YfL �1�1 Risk Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: / Mobile Pre-operation ` Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) . V W Time Bed&Breakfast P In: Othe U� j Inspector Out: 0-L/ rl p✓, Each violation checked req res an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS [d ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additivesku t ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP\ ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations 4 ` Critical(C)violations marked must be corrected immediately. (blue&red items) 4 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 `� 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 ❑ 90 Embar checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Emergency Closure El Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 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 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If B-One critical violation and less than 4pon-critical violations if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot )( ) aggrieved b 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.Physical Facility (FC-6 590.007 99 Y Y g g q violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address = 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature 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 Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N .-.... -•..,., .` ..a .-�. s -r... ._. �_...•....y....^- ..�".--ti.-.�ls.. . _ _ - - ._� r... - ._ .� `- r .__ - Violations related to Foodborne Illness - Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) I and Risk Factors(Red Items 1-22) (Conti) 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* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - �. - 3-302.14 Protection from`UnapprovedAdditives Contamination from Raw Ingredients 15 Poisonous of Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to ' - -- Other* 7-102.11 Common Name-Working Containers* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An _ _ _ _ 3-30 7-202.11 Restriction-Presence and Use*2.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report TiThe Person-In-Charge* 7.202.12 Conditions of Use* uirements 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance-Requirements 590.Q03(G) Reporting by Person in Charge* -'Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) _ Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and P 4-501.111 Manual Wazewashin 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,Peso Control and * 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. f 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* ' 3-401.11 A(1)(2) Eggs-155°F 15 sec 4-601.11(A) Clean Utensils and Food Contact Surfaces of E Equipment s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Eggs Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-441.11(A)(2) Comminuted Fish,Meats&Game Pathogens* E6 cri-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* E4-703.11 Frequency of Sanitiz `on 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 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 1pProper,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 . Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165`F* foodbome illness interventions and risk factors. * 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. radicsshould 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 TQ 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 foodbore 1 * 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 �r * 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 5-203.11 Numbers and Capacities* Within 4 Hours* 2 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. 1 Poisonous or Toxic Materials I FC-7 1.008 HACCP Plans i 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1 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 590.0.OQ, *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. p TMET TOWN OF BARNSTABLE H .LTH.INSPECTOR�s Establishment Name: Wte-" vV �!� Page: of OFFICE HOURS PUBLIC HEALTH DIVISION �, \ 8:00-9:30A.M. i BARNSTABLE. • 200 MAIN STREET VVV 1 113:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ;';39: �0� HYANNIS, MA 02601 MON.-FRI. P 54 sos-ss2 asaa No Reference R-Red.Item PL INT CLEARLY M FO D FESTABLISHMF NT INS RE T N REPO R Name Dat v Jag-0- vne of Ins ep ction Routine Address Risk Food,Service Re-inspection Level Previous Inspection Telephone Residential Kitchen Mobile Pre-ope Owner HACCP Y/N Temporary uspect Illness Caterer General qbmplahpt Person in Charge(PIC) M Bed&Breakfast HACC Other InspectorQX I a Each violation checked requires an explanation on the nary ive 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) ❑ e FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands _ ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS P ❑ 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/TEMPERAI URE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures - ' ❑5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding ) PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) OL ❑ 9.Food Contact Surfaces Cleaning.and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories „r��(�'/l Violations Related to Good Retail Practices(Blue Items Total Number of Critical Violations /VA/ Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ,. ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number-of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than Orion-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 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 y ty . (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critic I violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials '(FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 non-critical v''lati p=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: sp c 's Si at re (j' 6,PrinT 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N T #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI s ig. u Prin Self Service Wait Service Provided Grease Trap Size Variance Letter Posted . - Y N7q 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) [Demonstration signment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) 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.* Additives* 19 PHF Hat and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 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* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 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* * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 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 Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* . Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* e//c&e rrrnoor 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 r f Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS n 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* Proper,Adequate Handwashing Ratites-165°F 15 sec* ing'mobile food,temporaryand residential 10 Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g, g g 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 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 8 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 3-202.12 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 FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.600. Qp Vff ro TOWN OF BARNSTABLE _ HEALTH INSPECTOR•s Establishment Name: 0 �00D Date. Page: of v` ryo OFFICE HOURS ✓/ • BAR E. PUBLIC 2 0 MAN STREET 3:30-4:30 P.M.SION - : 0- :30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �A a39:a.� HYANNIS,FOOD ESTABLISHMENT INSP CT MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY r 508-862-4644 FD 39. ON REPORT ) Name Dat a e Tyne ne of Inspection i Routine Address Risk Food Servi Re-inspection Level Previous Inspection Telephone Residential Kitchen Mobile re-operatio - Owner HACCP Y/N Temporary Illness v Caterer General Complaint / Person in Charge(PIC) Time Bed&Breakfast HACCP rf In: Other Inspector Out: . Each violation checked requires n explanation on the narrative page(s)and a citation of specific provision(s)violated. / Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ .Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 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 ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 Emergency Closure ❑ Voluntary Disposal Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board'of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils 6=One critical violation and less than 4npn-critical violations 9 (FC-4)(590.005) cited in this report may result in suspension or revocation er 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 Physical Facility C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents-or insects,or lack of 27.Ph y y (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 n n-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Ins e i Pri 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N Frozen Dessert Machines: Outside Dining Y N PI 's Si tur I Print: #Seats Observed N Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y NNA MAO Dumpster Screen? Y N ;. Violations related to Foodborne Illness Violation Related to Foodborne Illness Interventions T 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* 6 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Conta 7-102.11 Common Name-Working Containersiners* 590.004(F) p g * 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated 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* 27 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a 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* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff crtvc umoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* A Stuffing Containing Fish,Meat,Poultry or 590.009 Ratites-165°F 15 sec* ( )-(D ) Violations of Section 590.009(A)-(D)in cater- Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail * 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 3-201.17 Game Animals g 9 Requirements. $ 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 * (Blue Items 23-30) 3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* IF 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours*. 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures I 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 I.Reduced-Oxygen Packaging Criteria* 8-103.12 1 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. Op THE Tp TOWN OF BARNSTABLE _ HEALTH INSPECTOR,s Establishment Name: d ' Date: Page: . �� of k$. OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30-430 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 MON.-FRI. No Reference R-.Red Item PLEASE PRINT CLEARLY 508-862-4644 'FON1 F qOD ESTABLISHMEN INSP CT ON REPORT E D t Tvoe of Ins ection g Routin Risk /,-Food Se 7 " spection Level Previous Inspection .� ne Residential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP Other InspectorZfTii Each violation checked requires an explanation nth narrative ages)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color.Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes, Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance. ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils B=One'critical violation and less than 4non-critical violations 9 (FC 4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation'F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If p,infestation of rodents or insects;or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a•hearing. Your request must C=2 critical violations and less than 9 non-critical. If no.critical water,sewage back-up,. 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 n n=critica violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. lation,4 to 8rion-critic iolatio C. 30.Other DATE OF RE-INSPECTION: I pest is Sin re ri j 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' ignature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted. Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202:12 ' Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 _ PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F * - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*7-102.11 Common Name-Working Containers 590.004(F) P g * 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* 3-304.11 Food Contact with Equipment and Utensils 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* 7-203.11 Toxic Containers-Prohibitions* ( ) 9 Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* -REQUIREMENTS FOR - 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and 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 1 Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,PH. 16 Proper Cooking Temperatures for PHF9 CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* Equipment 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* effe crier riuzoa 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practiceRequues should be debited under 929-Special $ Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) MI's 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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 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 3402.12 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 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging.Criteria* _ 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. B,RNST B «' PaulJ.Canniff,D.M.D. MASS F.P. Thomas Lee Alternate 109. 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: 188 Issue Date: 01/01/2021 DBA: CENTERVILLE FOOD MART OWNER: S. K. MART INC. Location of Establishment: 1149 FALMOUTH ROAD CENTERVILLE„ MA 02632 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: z �p[NEFor O tp� ffice Use Only: Initials:Town of Barnstable Date Paid,�_�/JDf� Amt Pd$ BAMSTABLE, ; Ins.pectional Services Es`0� 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 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): __ /� S A bo ae E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: .v -V- 7 TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO �r ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: bl---�SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) I/FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED& BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) OBILE 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: j.. FULL NAME OF APPLICANT N11/7W/1/11" Z—A SOLE OWNER: YES/NO ® OWNER PHONE# j o S -(Ito _.I b yq ADDRESS_ Z 7 4,-J+C4,Lj S A P, M jV PS-Ce wtr N&j-S M d b 2-1.G/,v CORPORATE OWNER: , CORPORATE ADDRESS: �`�� � G-lYll�i� �� �¢.vG,/G�.. /VI OL-4-,�.2— PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I 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 M17 SIG RE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments, including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at htti)://www.townofbarnstable.us/healthdivision/applications.asy. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. i NOTICE: Permits run annually from January 1 st to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES,BY DEC 1 st. R, Q\Application FormST00DAPP REV3-2019.doc OEIKE Town of Barnstable BOARD OF HEALTH John T. Norman Board of Health Donald A.Guadagnoli,M.D. URNWABM : F.P.(Thomas)Lee .b�� ..�� 200 Main Street, Hyannis, MA 02601 Daniel Luczkow Alternate 8" Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: 2021 Issue Date: 1 1 Permit No: 188 / / DBA: CENTERVILLE FOOD MART OWNER: S.K. MART INC. Location of Establishment: 1149 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: Non-Flavored Annual Seasonal FEES 2 1 TOBACCO SALES: $85.00 YEAR. Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY i t For Ofiiee Use Only: Initials: LD Town of Barnstable Date Paid, I Amt Pd$ � Inspectional Services 039.. Public Health Division E .orFa: p Thomas McKean, Director 200 Main Street, Hyannis,N A 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT.. PERMIT.APPLICATION,(Non Flavored} DATE Z0 NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: a TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: �)z z li-- 7/j/ s OWNER'S NAME:A!!� S L f// OWNER'S PH# d OWNER'S ADDRESS: o22-1_ec.1S CORPORATE NAME: S' • �� ��G CORPORATE ADDRESS:IICP%- LIHA�4 1Z6 I/✓&—CORPORATE FID# ANNUAL: L0011 SEASONAL: DATES OF OPERATION:_/_/ TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS).. IOVD z r TOWN OF BARNSTABLE CODE/MA GENERAL.LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: httttn s://male gis?at-are..goN,/Laws/GeneralLaws/Par.tINr/TVdeii Ciiapter27O/S ection6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 b, r SIGNATURE: i. s PRINTED NAME:,/ ��..................• ��} //� DATE: // 16 q 1. >-V Q:Wpplication Forms\TOBACCO APP-NonFavor 12-18-19.docx ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors— 371-9. Sale and Distribution of Tobacco Products.,. 1, No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. s 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-:issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. q The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature Printed Name Date i M�ein/h�9 aG — z� Signature Printed Named Date Signature Prirlfed Name .� Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date i Signature Printed Name Date cation Forms\TOBACCO APP-NonFavor 12-18-19.docx Q:\Appfication F ------------------------------- ---------------------- `Ty4s.c"t15�T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T xx s Retailer License for Sale of Cigars and Smoldng Tobacco This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. S K MART INC Account ID: CRL-19982151-007 CENTERVILLE FOOD MART Location ID: 1998215I-0002 1149 FALMOUTH RD License Number: 688183296 CENTERVILLE MA 02632-3021 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2020 Expiration Date:September 30,2022 tiSs?r MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes tiFT ova This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. S K MART INC Account ID: CGL-19982151-003 CENTERVILLE FOOD MART Location ID: 1998215 1-0001 1149 FALMOUTH RD License Number: 151312384 CENTERVILLE MA 02632-3021 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws tc sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2020 Expiration Date: September 30,2022 MASSACWUSETTS DEPARTMENT OF REVENUE Retailer License for Sale of Electronic Nicotine Delivery Systems ig w This license must be posted and visible at all times.The sale of tobacco products to anyone under 2t years of age is prohibited: S K MART INC Account'tD,: EDL-199821.51-012 CENTERVILLE FOOD MART License Number: 1534912512 1149 FALMOUTI RD CENTERVILLE MA 02632-3021 'This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above. This license is non-transferable and maybe suspended or revoked for failure to comply with state laws and regulations, Effective Date:August 24,2020 Expiration Date: September 30, 2022 9 t IRSDEPARTMENT OF THE TREASURY INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0023 Date of this notice: 07-08-2020 Employer Identification Number: 85-1820802 Form: SS-4 Number of this notice: CP 575 A SK MART INC 1149 FALMOUTH RD CENTERVILLE, MA 02632 For assistance you may call us at: 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN). We assigned you EIN 85-1820802. This EIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 941 10/31/2020 Form 940 01/31/2021 Form 1120 04/15/2021 If you have questions about the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year), see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue). Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. IMPORTANT INFORMATION FOR S CORPORATION ELECTION: If you intend to elect to file your return as a small business corporation, an election to file a Form 1120-5 must be made within certain timeframes and the corporation must meet certain tests. All of this information is included in the instructions for Form 2553, Election by a Small Business Corporation. s OFtF Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. R.atx.Nsrtate Paul J.Canniff,D.M.D. „ MA3 . 200 Main Street, Hyannis, MA 02601 F.P.(Thomas)Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 188 Issue Date: 08/27/2020 DBA: CENTERVILLE FOOD MART OWNER: S. K. MART INC. Location of Establishment: 1149 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: October 2017-TAKEN OVER BY CENTERVILLE FOOD MART-Variance was granted on 12-20-2017 to utilize the existing toilet facilty for the operation of a food establishment.Must provide two separate male and female toilet facilities for male and female employees. I For Office Us • Initials: �'"� .� Town of Barnstable Date Paid Amt.Pd$�� Inspectional Services 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 OS NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: /`l,� LZJ� 12yZ12P/ ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE):_L �:f�Z✓lL /yl� t? 152 E-MAIL ADDRESS: 6?�tfil�% Cofn• TELEPHONE NUMBER OF FOOD ESTABLISHMENT: rOL 7Z -7 TOTAL NUMBER OF BATHROOMS: &Vj�7-- WELL WATER:YES NO (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: 1,� SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: _f�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) ii 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 REV3-2019.doc OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES 9�0 /- OWNER PHONE# ADDRESS b 7 CORPORATE OWNER: /17RfWl1. S 4#,1iC CORPORATE ADDRESS: 24.? PERSON IN CHARGE OF DAILY OPERATIONS: l�-� 1I � 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 1.4&JA mA09t2 N 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 htti)://www.townofbarnstal)le.us/healthdivision/apl)lications.aso 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.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:1Application FonnsTOODAPP REV3-2019.doc 41 Town of Barnstable John T BOARD. , OF HEALTH Board of Health Donald A.Guadagnoli,M.D. RAWNSTABLL Paul J.Canniff, D.M.D. MA F.P. Thomas Lee Alternate +�39 200 Main Street, Hyannis, MA 02601 tea ° Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 188 Issue Date: 1/1/2020 DBA: CENTERVILLE FOOD MART OWNER: S.K. MART INC. Location of Establishment: 1149 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, IRS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY 7; tME For Office U. Initials• E Town of Barnstable Date Paid Amt Pdasr- MAW Inspectional Services —ono Public Health Division e`1eC'`# ` — -- Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT_PERMIT APPLICATIONINon-Flavored) DATE j12 NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: 60��, A-p7-.- ,g,�[ , ADDRESS OF TOBACCO ESTABLISHMENT: 9 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: C/ /Qp TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: J-O OWNER'S NAME: /!7(/! /l7 ` . OWNER'S PH#Ij:&j�ZQ-j4W OWNER'S ADDRESS:, 6 CORPORATE NAME: n CORPORATE ADDRESS: f,[� ffff�.� CORPORATE FID# g�/Q?.0 �07 ANNUAL:T SEASONAL: DATES OF OPERATION: J l TO I I DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN.OF BARNSTABLE COMMA GENERAL LAW INTERNET LINKS: 4 TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: hgps://www.ecode360.com/33996392 j MA GENERAL LAW CHAPTER 270/SECTION 6: https://malep_islature.j-ov/Laws/GeneralLaws/PartIV/TitleI/Chapter270/Section6. ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: i 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: IVIai�7/7�IrI DATE:,V9/ &/-70 Q:1Appfication FormATOBACCO APP-NonFavor 12-18-19.docx I ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—&371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Sign Printed Name Date Signa Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date C:\Users\decollik\AppData\Local\Microsofr\Windows\INetcache\Content.Outlook\YZOF4J38\TOBACCO APP2019 dob.docx i �4 Grmmrrmraalth or�i.ssudutsrdss Let cr It):1-0059501536 as Noficc D3t,:August 24,2020 G;p7ttmcnt of Revenuc 1 Geoffrey L Snyder,commissimer Accoi ntlD;FDL-l9q&2151-0I? ON nrass.govfdur LICENSE FOR SALE OF ELECTRONIC NICOTIN E: DELIVERS'SYSTEMS llntllt111tt1t11111tltllnlLtlil{111!Illlhlflillllllll11 - s tc MART INC CENTERVILLE FOOD MART 1149 FALMOUTH R.Ia CENTERVILLE MA 02632-3021 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cott along tile doted Line and display at your business location. At any time,,you can log into your MassTalConnect account at mass.gov/masstaxconnect to view and re-print it copy ofthis license. If you have any questions about your license,call us at(6,17)887-63,67 or tar l-free in Massachusetts at (800)392-6089,Monday through Friday,8:30 a.m.to 4:30 p.m. DETACH 11ERP MASSACHUSETTS DEPARTMENT OF REVENUE to � r-� y Retailer License for Sale of Electronic Nicotine Delivery Systcrns This license must be posted and visible at all times.The sale of tobacco products to anyone under 21 years of age is prohibited. : S K MART INC Account ID: EDL-19982151-012 CENTERVILLE FOOD MART License Number: 1534912512 11.49 FAIMOUTH.RD CENTERVILLE MA 02632.3021 This certifies that the taxpayer named above.is licensed under Chapter 64C;of the massachusetta General laws to sell electronic nicotine delivery systems at the address shown above.This license is non-transferable and may be suspended or revoked for failure to coniply witli state laws and regulations. Effective Date:August 24,2020 Expiration Date: .September 30,2022 '�`�Y�` � C;utam�untttatNnri�l;icsac.Au cclS itdt rt[�7r 1{13:fra(1WA � "" �s E?�r�srtmcaiini Itc� nuz. Noicw DmtC AuMuEt24= 2020 n s 3 toofflvvI%snvlkr,commissimicr 1<rcztsnt.'a?rtat" li}}\'r�r-00's Fti}cw mass.et}�Ic1t?r SALES TAX ON NMEALS AM) BEVERAGES :REGIS,' RATION CER71141WATi: III III I1i11111 Jill r11b1111rti1 11 tltl'It"11'Ill' s K N1Alr71NC 1149 FALMOUT14 RD Attached below it your Sales Tax oil\l als atacd i�e\,cragcs Itegistration C;ertificate:;(l orm NIT-D..Cut atlortP the dotted lini grad display at t c ur'place of buainc,s.You must report ally change of rt:im e car address to us so that a cornet\4,r-1 can be issued. :1t any time,YOU Can 100 into your M.lss'TaxCounect account at m<ass.e;ovr'tnas.,t aac onnect.to view and re.-print a cope of this certiticate. DETACH IIERE� NIASSACHUSE T TS i)E 'At2"UMENT OF REVENUE Form Nl`i-t Sailer"I'.ax onttleals attci 13er et a;;es 12c;;trit attiata Cea that ale y? This rel;i, -alien must be laastcd :and visible:at all tinges. it S IC MART INC; Account 10: NILS-19982151-008 Cl-,N"CFRVIL,I, _1>()OD M:ywr C ertific ate Number: 729601144 1 149 FALMC)l!TH 1D C) NTERVILLI1, tMA 02632-3021. This cc rtilics that the taxpayer n:uaaecl above is rvivistercd under Chapters,62C.and 6-41 of the Massachusetts Genenal Lmvs to sell meals rand beverages at the addroN showat above.TIiis rogistratioll is tarn-ta:uaslcrahl .and may he suspended or revoked liar failure to comply with slate hmvs.,and regulat lolls, 1f,ffective Date:September 1,2020 .c'+rt.;t•, M:ASSACIIUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and.Smoking Tobacco s This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. S K MARS'INC Account ID: CRL-19982151-007 CENTERV LLI OOD MART Location ID: 1 9982 1 5 1-0002 1'1.49 FALMOUTII RD License Number:6881832% CENTERVILLE MA 02632-3021 This certifies that the taxpayer named above is licensed tinder Chapter 64C of the;Massachusetts General Laws to sell at retail at the address shown above.This license is nontransferable and may.be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2020 Expiration Date:September 30,2022 .. ,c.lfitPs,, MASSACHUSIETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes (")v This license must:be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. S K MART INC Account,ID: CGL-1998215.1-003 CENTERVILLE FOOD MART Location ID: .1.9982151-000.1 I t49.FALMOUTH RD License Number: 15.1312384 CENTERVILLE MA 02632-3021 This certifies that the taxpayer named above is licensed under Chapter 64C.of the Massachusetts G'eneraI Laws to sell at retail at die address shown above.This license is non:transferable and may be suspended or revoked for failure to comply N4ith state.Iiws and regulations. Effective Date: October 1.,2020 Expiration Date: September 30,2022 pFT�lOk, Town of Barnstable Barnstable �'"RMASS. � Board of Health 1 Qj .i63q �0 �fn yg ° 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Paul J.Canniff,D.M.D. FAX: 508-790-6304 Donald A.Guadagnoli,M.D. Junichi Sawayanagi December 20, 2017 Mr. Zahid Rashid Centerville Food Mart 1149 Falmouth Road Centerville, MA 02632 — Mart i Centerville Food RE: Variance to Operate with one Restroom Facility C Dear Mr. Rashid, You are granted a variance to utilize the existing toilet facility for the operation of a food establishment at 1149 Falmouth Road, Centerville. The variance granted is as follows: Section 322-4 Toilet Facilities To utilize one restroom in lieu of the requirement to two provide separate male and female toilet facilities for male and female employees. The variance is granted with the following conditions: (1) This variance decision letter shall be posted on the wall adjacent to the food permit in an area which is easily accessible to be read by a health inspector anytime routine inspections are conducted. (2) This variance is not transferable to anyone other than the applicant. In the event that this business is sold or transferred, both the owner of the building and the licensee have the duty to inform any and all potential purchasers of the existence of these variances and the fact the Board has explicitly made them non-transferable. ZauYJ'/C_aXn ely yours, �11 D. Chairman 4 Board of Health Town of Barnstable Q:\WPFILES\Centerville Food Mart ToiletVariance 2017.docx FTME TOE w zw `� �� DATE: N ,5�� FEE: S * IARNSfABLE, • .1j MAss. ll., �J l Se"-be Town of Barnstable r- a> SCHED.DATE: Board of Health coy 0 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Paul J.Canniff,D.M.D. FAX: 508-790-6304 Junichi Sawayanagi Donald A.Guadagnoli,M.D. Alternate:Cecile Sullivan,RN,MSN VARIANCE REQUEST FORM LOCATION Property Address: IZ4!2 )&z2 Assessor's Map and Parcel Number: Size of Lot: 4 O7,aneea Wetlands Within 300 Ft. Yes Business Name:` l G- No Subdivision Name: rr/� � APPLICANT'S NAME: ZWA940 , Agily. Phone JOt?— 737-O 0'T Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON Name: Name: 7A�7� /'fcR�if1� Address: Address: D �7 ���. Phone: Phone: 'jp8 7.37 OA0fcx --�EMAIL: .PftZ�ogif,�V kC• COAT - VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach i more space needed) 322. 3 'S' u. NATURE OF WORK: House Addition House Renovation Repair of Failed Septic System Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 5 separate,collated packets. Five(5)copies of the completed variance request form Five(5)copies of engineered plan submitted(e.g.septic system plans) Five(5)copies of MA DEP approval letter for UA septic systems only. Five(5)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) A completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or registered sanitarian Signed letter stating that the property or business owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu—Five(5)copies of full menu submitted(for grease trap variance requests only). $95.00 variance request application fee collected (No fee for lifeguard modification renewals , grease trap variance renewals [same owner/lessee only],outside dining variance renewals[same owner/lessee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Paul J.Canniff,Chairman NOT APPROVED Junichi Sawayanagi REASON FOR DISAPPROVAL Donald A.Guadagnoli,M.D. C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\BMQD49H2\VARIREQ Rev APR2017.DOC M. S. MART, INC (DBA) ZAH I D RASH I D CENTERVILLE FOOD MART 1 149 FALMOUTH ROAD CENTERVILLE MA 02632. November22, 2017. O RAZEE298@GMAILCIOM To Whom It May Concern: !" Dear Sir or Madam: O Thank you for takingour time to review m application for Y PP Y 508-737-0890 reopen the Centerville Food Mart on Friday 1149 FALMOUTH ROAD December 1,2017 As I said I have every attention to meet all ' CENTERVILLE MA 02632. the requirement ASAP. I. Submitting a variance request from for the allow to operate the location under one bathroom. 2. Repair for the septic system plan have submitted by the Engineering Works, Inc. once the plan is approving by the health department R J Bevilacqua Construction Corp will schedule installation with in days until then I have Bousfeld Septic Pumping will pump as needed. 3. Servsafe certification been schedule for two more people. Please grant me temporary license for 90 days. Thank you in advance for your help in this matter. Sincerely, Zahid Rashid z �- `� -_ ee _w. pr ------ ._ }5' - AIN • Oi tAl 3- • � i , r J F s - - L C j.. 4 - - S 77u - r L 1 i At S 4 Y:: 77 p 7 L. )(,Dot" _ �.. .� W��4- I�KK �C' 'iC' .ws�•E2 .. . A �p 412 mo �49 . n 11 +.._�...rr�.s* :.••N ..: --� �.,..._.1 _f��. } .� �_,...., � _....�-._ t 4 � Ate} � � 3 � OIV - P..•'.row. --+�}� -,.Ui..� ,.j- .�._•y,....�.a _,�...._-?.._ ..-,r.._..p..__..,a._.. , � -.-i.-. � .-,t. S�C i _�, e... j s -3 + �:+.--.... .n. re^.._'—��....y.+f^^`^'F"ar.• I )� f i ,��. P _± �_. '8$� . { � t_ p _/-` s ...:. ._ , ic y4-1 ..;--.�S......s-, _'..«. �,...-.:.�.e.`^_3" �'•A�-^ f-lt �P `+oac...--.e.-• _ ' f �i �- s � 1__ t ; '� 1 3 y� S jf '0 T, 77 - - 1 L � t_ } z { {_.. a �..,. t _ 1-•-�.� ._.. _�.. �._.E_ ._}c..:. ..,(�,._._.,.___#-"r'4L___ .....�.._.mot i -� - ---.._ _.. ._f` ' _� ' . d 1 w Poo m � 4, �J 0O � 1 3 exy aSlAll, �9 r` McKenzie, Marybeth From: John Simison <bousfieldseptic@bousfieldseptic.com> Sent: Thursday, November 30, 2017 1:21 PM To: McKenzie, Marybeth Subject: Bousfield Septic Pumping Attachments: MS Realty Trust -Invoice#34045.pdf Hi Mary Beth, Attached is our invoice #34045 to MS Realty Trust for services at 1149 Falmouth Rd, Centerville. Please call 508-888-2010 if any question. Thank you, Joan Simison i SEA STAR SEPTIC PUMPING, INC. I n yo i ce d/b/a Boustield Septic Pumping _.. P. Number: 34045 .0.BOX 492 FORESTDALE,MA 02644-0492 Date: 29-Nov-2017 PHONE (508)888-2010 P.O. Number: Job Description: FAX (508)888-9365 Order Num: 34045 Serviced 28-Nov-2017 BILL TO JOB SITE MS REALTY TRUST FOOD MART ATTN: ZAHID RASHID 1149 FALMOUTH RD/ RT26 26 PLESANTWOOD DRIVE CENTERVILLE, MA FORESTDALE, MA 02644 Quantity ServiceType Amount x2 Men Tax Extension 14(3G pkjmptiNG SEPIVd rGE $(1.22 Sao Ito $220.CYJ TANK#1 -SEPTIC - LIGHT SOLIDS/SLUDGE-PUMP YEARLY 1000 PUMPING SERVICE $0.22 No No $220.00 TANK#2-GREASE - LIGHT SOLIDS/SLUDGE-PUMP YEARLY Taxable Amount Tax Rate Tax Description Subtotal NonTaxed: $440.00 $0.00 Subtotal Taxable: $0.00 Subtotal Tax $0.00 Payment Terms:NET 10 DAYS Less Payment: $0.00 Please Pay: $440.00 WE ACCEPT VISA,MASTERCARD,AMERICAN EXPRESS&DISCOVER CARD. n11MItnItnWl Attnnllpmm�Nnnnlnn.MnnNttollntu.w.�nnw.nlwnitn111ptnnnnYMlntw�upl�Mnlunnitlnnn111nntnnn111iOM1M111 WlMImgYlYtl111nn�p111no YMlnntwt�YUln�nntnYsnnvXnntn��nlN��1r11�.taltll�emYO�t From: Please detach here and return the bottom portion with your payment, MS REALTY TRUST ATTN:ZAHID RASHID Order No. Invoice No. Date Amount Due 28 PLESANTWOOD DRIVE FORESTDALE,MA 02644 34045 34045 29-Nov-2017 $440.00 To: SEA STAR SEPTIC PUMPING,INC. d/b/a Bousfield Septic Pumping P. 0. BOX 492 FORESTDALE, MA 02644-0492 i Miorandi, Donna From: Bellaire, Dianna Sent: Monday, September 30, 2019 9:15 AM To: Miorandi, Donna Cc: Bellaire, Dianna Subject: Centerville Food Mart Hi Donna; I noticed this variance is on the permit for them, does this still need to be on their permit? October 2017-TAKEN OVER BY CENTERVILLE FOOD MART-Variance was granted on 12-2.0-2017 to utilize the existing toilet facilty for the operation of a food establishment.Must provide two separate male and female toilet facilities for male and female employees. Dianna Bellaire Permit Technician 1 Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us 1 1,� e.. No. _ Zll� '�� Fee THE COMMONWEALTH OF MASSACHUSETTS Enters din comp ter: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,MASSACHUSETTS 2pplicatton for Mtopooal *pgtem Con6truction Permit Application for a Permit to Construct( . )Repair( )j Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. #'11(.19 !=A)MO Vf A Owner's Name,Address and Tel.No. _ 7# `7- 6/PVPj Cs6;vt'rJ1Pn>G8lTcfl- Assessor's Map/Parcel y b'0 0Q' Installer's Name,Address,and Tel.No. 0S-j Designer's Name,Address and Tel.No. (la RoQe�� Af�!}ke p,t (S08)q 1`l-5 0qa P.o, ,6QK Is57 oZ6rfS GGoGtHfi,110 1)t�v-L f "C . to / Type of Building: Dwelling No.of Bedrooms Lot Size l.a y sgrf Garbage Grinder(/vo) Other X Type of Building STo A 15 Ne_ef-�'erst� : (n 8,5 s-.FT Showers(n4) Cafeteria WO) Other Fixtures Design.Flow SO GA 114 as 29.PT. gallons per day. Calculated daily flow gallons. Plan Date / IS-oe Number of sheets I Revision Date Title PP-GP3567j) SG PTI C S YSTUM V P6tfff Size of Septic Tank i ovQ Rll©:jS - 6Vi71w6 Type of S.A.S. l--�°a C AC 'TAtvk 1;co l l c r/ �ceas t+T 1► f �/ `o F S TQ,v 9. Description of Soil T,-P iy.. c���71NG F,IL Nature of Repairs or Alterations(Answer when applicable) 7N T� C�r P•6 N e W S'!�I F'I e Ccd 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 Environmental Code and not to lace the system in operation until a Certifi- cate of Compliance has been is ed by this Board of Health. Z 6 i;j(,l,P(4D DIN Signed G n G Dart, f Application Approved by dle Application Disapproved for the following reas Permit No. Date Issued f �jr q No. Fee Fee 'THE COMMONWEALTH OF MASSACHUSETTS =Ente!rd in computer: Yes `= PUBLIC HEALTH DIVISION -'TOWN OF BARNSTABLE, MASSACHUSETTS application for VWpooal bpztem Con!Wuction Permit Application for a Permit to Construct( )Repair )Upgrade( )Abandon(� ) ❑Complete System j0 Individual Components Location Address or Lot No. #-f f q 9 Fry.)mj v-f A f-oAj Owner's Name,Address and Tel.No. La -T— C(PYP,) CaMvPNIPNCB S 10/i $. Assessor's Map/Parcel �� D07pd4. Installer's Name,Address,and Tel.No. m Designer's Nae,Address and Tel.No. - (Co&i-1 OVX COMPANY (So5) `l32 -oS3i Rr'Ger� br.4ke, P.C . (Sa9�Ny7 -So�18 P.o, 6'K ISM o�6y.5' 6C 6epe,kv�le OXIVt r o I• " A OJ6. Type of Building: u Dwelling No.of Bedrooms_ Lot Size 1, 0Q1 4-ft- Garbage Grinder(ko) Other X Type of Building o E .l"f-Pogs@ns Z,f 9 g sQ. FT Showers(a),Cafeteria(Ajp) Other Fixtures Design.Flow S6 GA S4.FT. gallou&per day. Calculated daily flow gallons. .. Plan Date /- /S'-Oe Number of sheets 1 Revision Date `• y Title PrilwilScj) SC P71C SYSTEM UPGxAnIE� Size of Septic Tank 1,tea q I Jogs'' E V 7/� Type of S.A.S. /-J-oil G A( 7Q N k X , +� Description of Soil ;Nature of Repairs or Alterations(Answer when applicable) 46 P w S A_r F"I p (j 4 Date last inspected: r Agreement: " 1 . a TheCundersigned 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 Environmental,Code and not to lace-the system in operation until a Certifi- ,. Cate of Compliance has bee iss ed by this Board of Health; , ) (��� /(� -• Signed 7 ` a f _ DaAAt�� 5 Application Approved b ��45)lfilfllll Application Disappioved for the following reaso tip.. Permit No.j��4) Date Issued F f — THE COMMONWEALTH C'F MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( X)Upgraded( ) Abandoned( )by ( , e �/" at 1 has been, constructed in accordance with the provisions ofTitle 5 and the for Disposal Syste Construction Permit No. -" Jcdated Installer oU I— Designer The issuance of this peymit shall not be construed as a guarantee that tsy t ste�ryw*11 un tion as designed. Date o S Inspector No. 1 / C,�--_—.— .�—�_....,.-------•+------- Fee ! !�/T".� THE vvr ervvvai�.A.'`. fY OF IVIAJS%iiri'1Lljtl 15 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSE fS MigogaY J gteITC Con!5truction Permit a, Permission is hereby granted o Construct( )Repro' ( )911, ad )Aband n System located, � 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: C nstructp�n m>st be completed within three years of the date of tti s-erm 1. ll c Date:_. 1'{� ? A roved b r Town of Barnstable * eauvsrABIX Regulatory Services Department . MAN 039. Public Health Division s63q `0 FD Nt°s 200 Main Street, Hyannis MA 02601 Office: 508-7904644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $50.00 MAIL TO:TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$50.00 APPLICATION FOR A TOBACCO SALES PERMIT LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL D/B/A / O620� /-'F STREET ADDRESS a8-77 6- ���� - TELEPHONE # FID# Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand the Sections VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form (provided herein). Signatur Date Q:\Application Forms\TOBACCO APP.docx TOBACCO SALES TO MINORS PROHIBITED BY MASSACHUSETTS GENERAL LAWS Sales to Minors — Massachusetts General Laws Chapter 270, Section 6, whoever sells a cigarette, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen (18) or, not being his parent or guardian, gives a cigarettes, chewing tobacco, snuff, or tobacco in any of its forms to any person under the age of(18), shall be punished by a fine of not less than one hundred dollars ($100) for the first offense, not less than two hundred dollars ($200) for the second offense, and not less than three hundred dollars ($300) for any third or subsequent offense. Posting State Law — In conformance with Massachusetts General Laws Chapter 270 p , Section 7, a copy of.Massachusetts General Laws Chapter 270, Section 6 shall be posted conspicuously by the owner or other person in charge thereof in the shop or other place used to sell cigarettes at retail. The notice to be posted shall be that notice provided by the Massachusetts Department of Public Health. Such notice shall be at least 48 square inches and shall be posted at the cash register which receives the greatest volume of single cigarette package sales in such a manner so this may be readily seen by a person standing at or approaching the cash register. Such notice shall directly face the purchaser and shall not be obstructed from view or place at a height of less than 4 feet or greater than 9 feet from the floor. For all other cash registers that sell cigarettes, a notice shall be attached which is no smaller than 9 square inches, which is the size of the sign provided by the Department of Public Health. Such notice must be posted in a manner so that it may be readily seen by a person standing at or approaching the cash register. Such notice shall directly face the purchaser and shall not be obstructed from view or laced at a height no less than 4 feet or more than 9 feet from the floor: Establishment Q:\Application Forms\TOBACCO APP.docx I r TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood sections VII b. and VII c. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of eighteen(18). Below are sections VII b. and VII c. of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file, in the office of the employer and retained. Such signed forms must be made available for inspection,during the license holders normal business hours upon request of an agent of the Board of Health. c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age, the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIIb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking � P Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Si afore Printed Name Date sirnatdr-d Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP.docx f r r FOR MAIL-IN REQUESTS Please mail a completed tobacco sales permit application form to the address below. In addition, please include the required fee of$50.00. The check should be made payable to: Town of Barnstable. Allow five to seven(7) working days for in-house processing. Our.mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED REQUESTS Our fax number is 508-79076304. Please fax a completed application form. In addition, you must mail the required fee of$50.00 to the address listed above. Please make the check payable to: Town of Barnstable. Allow up to four days for in-house processing. For further assistance on any item above, call 508-862-4644 To get a tobacco sales permit application form, click here. To be able to access this form,your computer must have Acrobat Reader. Most computers have Acrobat Reader, and it will usually activate itself automatically. If your computer does not have Acrobat Reader,you can download a copy of it by going to the Adobe website. Back to Main Public Health Division Page Q:\Application Forms\TOBACCO APP.docx oF� Town of Barousiable r# Department of Regulatory Services Public Health Division Date [3v 112 200 Main Street,Hyannis 1VtA 02601 Date Scilt duleii d' I�1 1 J I f 17 Time '16 A �^^ 4 1 �r•�,;� Fee Pd. Foil Suitability Assessment,or ,Sewage Disposal Performed:B : -Fe�te✓me ce, }-�.Q C,r✓ f 5 i}2. y y Witnessed By: PiJti z-s mio i 5' LOCATION & GENERAL INFORMATION Location Address i !� Owner's Name. "t �(iMc��-lam 12�( � 5; 4x_K.o1 ram- 2 Address C`U "7--!✓QSt 0 L.13 1/U C- t0,10, �X 7 11 u�i VtS' Tj� _7S ZZ i Assesso1.r's M.plAarceI., -z rL I t,o o _d 0� Engineer's Name o �g t n�e+�'� �7 l � NEW CONSTRUCTION REPAIR —� Telephone# SO —t 7 7—5-3(3 Land Use Slopes(%)� Z SutfaceStones PjioAA _ Distances:from: Open Water Body ft Possible Wet Area ft Drinking Water Well C 0ft Drainage Way ft Property Line 2U �� ft Other ft SKETCH:(S.treecname,dimensions of lot,exact locations of test holes&perc tests,locate wetlands'fn proximity to holes) �tr �n� '' y � Z Parent.material(geologic) v "rw Depth to Bedrock: A/d/V J� Depth to Groundwater: Standing Water in Hole: AJld (u Weeping from pit Face FstimatedSeasonal.High,Groundwater > ��- DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: _ in, Depth to Sol]mottlev. Depth to weeping from side of obs.hole: in: Groundwater Adjustment ft. Index Well# 'Reading Date: Index Well leveler Ad.l.ractor— Adj.Ornandwater Uvel PERCOLATION TEST bate�. Tlme..�.� Observation Hole# e {`- , Time at 4" Depth of Pere z 4 Time at 6" Start Pre-soak Time @ -- q%;`' L v►G t:-� Time(9"-6") End Pre-soak tNl l�t►z .h 10 ZS �� Rate Minlhtch. Site Suitability Assessment. Site Passed V Site:Failed: . Additional Testing Needed„(YIN) Original: Public Health.:Division Observation Hole.Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you.must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\FERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structum-Stones;Boulders. -on isten :Gravel) A c -34 f" SA%,tAa lamirt, LOYtz 5AL DEEP`OBSERVATION HOLE LOG Hole# 'Z Depth from Soil FIorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% rave L L DEEP.OBSERVATION DOLE LOG Mole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Muosell) Mottling (Structure,Stones,Boulders. C nsistency. oGravel) DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure;'Stones,Boulders. Consisten .r Flood Insurance Rate Map: ear flood bound�Y No_ Yes Above 500 y , Within 500 year boundary, No Yes Within 100 ye ar flood boundary No Yes Death of Naturally Occurring Pervious Material Does at least.four feet of naturally occurring pervious aterial mst i all areas observed throughout the area proposed for the soil absorption system? . If not,what is the depth of naturally occurring pervious material? Certification I certify that on h �l�el.1 .(date)I,have passed the Soil evaluator examination approved by the. Department of Environmental Protection and that the above analysis was performed by me consistent with the required traini expertise and experience described in.310 CMR 15.017. Signature �- Date Qc\4Ep nc1pBRCFORM.DOC i THE COmmai, EAL'TH OF MASSACHUSETTS BOARD PF HEALTH .......... >...........OF....... /!/�-1 �r ................................ .................. Appl ration for 11iopoottl 19orko Tonsuvr#ion rrruti# Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal Systemat V44 ..... .......................`..-- _..._.............._.........._...... Loc ...... at... Ar" .A lt` .............................. ..... .---......_................ Lot No. ........ ... ... ......... wner •-.-. Address w .............. � -A^ti......_......... - .................._........... ................_._.................... ......... Installer Address Type of Building Size Lot...._. �. U Dwelli —No. of Bedrooms............ Expansion Attic Garba a Grinder 2---- -------------- P ( ) g aOther Type of Building .52K.�.......... e- agns � r .4. Showers (N�— Cafeteria L8 dOther fixtures ................................... 5 ---••-•....................................••-----•---•-----...........--------.....-----•-- W Design Flow.............. ...................gallons per p -� ......_y far. Total daily ..............,�3 ................g�llonsd WSeptic Tank—Liquid capacity.l ?gallons Length.... .......... Width... . Diameter................ Depth... ... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No......... .......... Diameter........f...... Depth below inlet....... ...... Total leaching area,;ZW......sq. ft. Z Other Distribution box ()< ) Dosin to _��...... .. Z a Percolation Test Resul sZ Performed by._ n�`�'-. •... ..................` ............ Date... �.._��..:g........-� Test Pit No. 1.�.-...-.-..minutes per inch Depth of Test it...._,� ..j....... Depth to ground water. ed� . 44 Test Pit No. 2................minutes per inch Depth of Test Pit... ............ Depth to ground aj........ ...... .... ... Description of /:Soil..... . ----•-• ;........................ ....... . -- ' �. ..... ........................................................ xrt•�E �G-......T c u� ---------.......---•-------------------------------------------------------------------------------•--•-•-•••••......... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •--•---•..................................•--.............................---•-•--.......------••---•-••---•--•-------------................................----............•-•••-......•••.._.......... Agreement: The undersigned agrees to install the aforedescr' ed Individual ewage Disposal System in accordance with the provisions of TITLM 5 of the State Sanitary Co —T e d signed further agrees not to place the system in operation until a Certificate of Compliance has been u oard of health. ` Sign •. .............•.... .. .. ... .. Application Approved By... ................... .•. Date Application Disapproved for the following reasons:............... '--- �,n,,. --•-.. ... .......................• ._......___ r ........•................................• •------•-•-•----......................................---•-•---..__.... ........... Date » PermitNo....................................................._.. - IsstCec�.................................................. .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD, OF HEALTH_ ......... Appliration for 11isposal Works Tontrudion ran it Application is hereby made for a Permit to Construct) or Repair ( ) an Individual Sewage Disposal System at: _ ___ _ . of - = � ....... .�..».. .. ' f: ion .l f .»...................... ..................•---..._................or Lot.No.......................a...._..... c`..' ... 4 .. rgwner .r� .......... ...........Address .......... ..I taller......1 �.MCr14ya................. Address...................... .... ....... Type of Building Size Lot...... ,.:..... .....sq: W U Dwelling—No. of Bedrooms.......... ............... Expansion Attic ( ) Garbage Grinder �'..•d Other�M a of Building '2f.r .. � � Showers � Cafeteria .... Other fixtures _ W Design Flow..............`' . ..................gallons per ps> -per day. Total daily flow................ ? , .- ...___......gallons. WSeptic Tank—Liquid capacity._.>-5:�_K;gallons Length.....:l?.._ Width... .-Z! Diameter................ Depth.. ::1 x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No..... �..I........... Diameter........ Depth below inlet......4......... Total leaching area; !!: ......sq. ft. Z Other Distribution box ( ) Dosing,tank (_ ) `-' Percolation Test Results Performed by...4:`�`-` ��: I UP " %{•��'°�?' Date...,��..:�t..: a .... y..... ........f....... ' .._. Test Pit No. 1.. ._........minutes per inch Depth of Test PIt._._.,.2?1...... Depth to ground water. _(2:'./..-.L-.1 t fs, Test Pit No. 2................minutes per inch Depth of Test Pit.../�:......... Depth to ground water.r.�u r;.j�, f.�i �_........1....... r �..... ... ../..............f. =.......ei............ .......... O Description of Soil...... '`- ' �✓f. 'f•j,, ifs/ .' ..I 77 W ...............•---•. ........ -------------------------------------------•--•--------•---•--...-----...-•------------•...........-----.......--------------------•---•----------.................•--.................................. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---•......................•-----------..----................._ :.:.............---.....•••------•-•---...............---•---------•-•--....---•-...---•-•---......................--•.................. Agreement: The undersigned agrees to- install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLs 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.....f.........-••••-•--•-----•••-----•-•••----•................................... .......................Date ... - Application Approved r ..././,�'� 1112................ Application Disapproved for the following reasons:................'.,.- --•-- --- ...........................................Date »»Y ,/ ...................................................•---...--•-----..............--•---.......•--. ..................................................w......_.............. Date...........» PermitNo....................................................»»_ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... # Trrtifiratr of Tautphanr THIS IS TO CERTIF,rIrj,That the Jndividual Sewage Disposal System constructed ( ) or Repaired ( ) by....--•.....•-••••................•-•-......� ...........--=-=r' ----.....--•----•-•--....--- -----•--•---............-•---•..............-•---•---....................»».._.... nsiller has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Coqe as described in the application for Disposal Works Construction Permit ................ 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 �w BOARD OF HEALTH J 3�t��o,�ttlork� ��rtr�cti�a'n �er`utit�~-' Permission is hereby granted..._.... �- �„ ,,<,.................................._._. _ fir_. .a....... ...........................................»»_» to Construct ( ) or Repair (� )�vl ual--Se h_►age Disposal Sys em at No. ... `/ - ...._. �1/ , ...-•-•---••---•. ------•........................................... . ._... ... ~+� street as shown on the application for Disposal Works Construction Permit No.,.... ......... Dated.......................................... ...... _ oardf .. s' . t. 1 ' Board of Health DATE ...... ................. . ..w ........... FORM C-1255 CITY & TOWN FORMS, INC.369-9208 .ti � r � , ,s Town of Barnstable Barnstable ti ` Regulatory Services Department AFAmeficaCilly lARNSUBLE . �� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4990 4032 October 17, 2017 SOUTHLAND CORP/C/O 7-ELEVEN, INC TAX DEPT 255942464 DALLAS, TX 75221-0711 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1149 Falmouth Road/Route 28, Centerville, MA was inspected on 10/06/2017 by Michael T Bisienere, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level,<12" below inlet (per Town Code 360-9.1). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\1149 Falmouth Road Centerville.doc THE rqy, ti Town of Barnstable BARN57AELE, XAM ,bg Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO REPAIR FAILED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) _ An`Y"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground w . ❑Pumping more than 4 times during the,last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). . - L 4 Single Cesspool• ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) . .,eaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: WSEPTIMEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts ' W Title 5 Official Inspection FormM, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 1149 Falmouth Rd RT 28 1,0; Property Address 'a Southland Corp. " Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017w-+- page. City/Town State Zip Code Date of Inspedtibn Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, C� use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return key. Name of Inspector Cape Septic Inspections ,Q Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority .r �i i. 0.6L2.017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 b"4 VS Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G'M 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A System Passes: ❑ 1 have not found an information which indicates that an of the failure criteria Y y e c terra described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. i Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N FIND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 1,00 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Store Design flow(based on 310 CMR 15.203): 243.5 GPD Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 2688 sq ft Grease trap present? ® Yes ❑ No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•'" 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: New leaching 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Standard H-10 1000 gallon septic Dimensions: tank Sludge depth: 1" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts a - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap (locate on site plan): Depth below grade: one feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: standard 1000 gallon Scum thickness Failed system I did not measure Distance from top of scum to top of outlet tee or baffle Recommend pumping Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts ' . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts ' - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: One ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the liquid level was just below the pipe. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts ' - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �,M ,••�'°� 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ' w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �Itrjc_� fj6- AL K (),r 51-vrt- ews Se Qs' ® S eeL �1 $Teel. G�✓t/ f �Uv lJ A L Gt7,4,,n 12✓ t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) �I Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 144" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: I Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plans at the Barnstable Health Dept. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts ' - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1149 Falmouth Rd RT 28 Property Address Southland Corp. Owner Owner's Name information is required for every Centerville Ma. 02632 10/06/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Summary Inspection® p D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 115 or attached in separate file t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ni m . • � ,x o 0 F F ir Certified Mail FeeIr Extra Services&Fees(check box,add fee as appropriate) ❑Return Receipt(hardcopy) $ 1i 0 ❑Return Receipt(electronic) $ Postmark O [:]Certified Mail Restricted Delivery $ Here 0 ❑Adult Signature Required' $ h r, ❑Adult Signature Restricted Delivery$ �� L 1-3 Postage m $ ,! rqTotal Postage and Fee SOUTH LAN D CO RP Ln Sent To C/O 7-ELEVEN, INC C3 StiaetandAp£No.,oi1 TAX DEPT 255942464 Zr+4------ DALLAS, TX 75221-0711 Certified Mail service provides the following benefits: Is A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this_"l delivery.` USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. :J signature)that is retained by the Postal Service'" Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,ory to the addressee's authorized agent 0 Important Reminders: Adult signature service;which requires the T ■You may purchase Certified Mail service with signee to be at least 21 years of age(not -'-0 First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which 4 Certified Mail service is not available for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified, ■Insurance coverage is notavailabie for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on r 1 •For an additional fee,and with a proper this Certified Mail receipt,please present your -1 endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for the following services: postmaridrig.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply T You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. ,J electronic version.Fora hardeopy return receipt, complete PS form 3811,Domestic Retum Receipt attach PS Form 3811 to your mailpiece; IMPORTARI:Save this receipt for your records. Ps Form 3800,Apri12015(Reverse)PSN 7530-02-000.9047 7SNPER� COMPLETE,THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items1,2,.and 3. A Signat ■ Print your name and address on the reverse X 0 Agent so that we can return the card to you, Addressee. A Attach this card to the Back of the mailpiece, B.R ived by(P ri ame v r C. Date of Delivery or on the front if space permits. 3 a � A D. Is delivery a rasa different fro item 1? ❑Yes SOUTH LAND CORP If YES,enter delivery address below. ❑No I l C/O 7-ELEVEN, INC TAX DEPT 255942464 : DALLAS, TX 75221-0711 f II I I I II II I I I I I I I I I I I I I I I I( I I I I)I I I I I I I I I I I I III Adult Signature Restricted Delivery O R�gtstered Mail Restricted 9590 9402 1934 6123 0978 38 �ed Mall® elivery Certified Mail Restricted Delivery erohandeoelpt¢or ❑Collect on Delivery n.►rrAo_n!i,—;ar ffrancfar 6nm_aa_evrna_ratia0 ❑Collect on Delivery Restricted Delivery ❑Signature Conflmistion*11 Anil ❑Signature Confirmation 7 015 11,7301100011 R9 90 14 0 3 21 j 'pall Restricted Delivery Restricted Delivery PS Form 3811,JUIy2015-PSN 7530-02-000-9053 Domestic Return Recelpt USPS TRACKING# First-Class Mail Postage&Fees Paid USPS I Permit No.G-10 I I 9590 9402 1934 6123 0978 38 I I United States •Sender:Please print your name,address,and ZIP+4®in this box• I Postal Service Town of Barnstable Health Division I 2001N1ain Sheet I Hyannis,MA 02601 I KCJ ENGINEERING ENVIRONMENTAL ENGINEERS SEPTIC SYSTEM DESIGN March 1, 2005 Mr. David Stanton, R.S. Health Inspector Town of Barnstable Public Health Division 200 Main Street Barnstable, Ma. 02601 Dear Mr. Stanton: lam submitting to you an As-Built drawing of the septic system upgrade for the 7- Eleven Convenience Store located on#1149 Falmouth Road (Route 28) in Centerville, Ma. I have enclosed one original signed site plan with ties and elevations for your records. The Robert Our Company installed the septic system on Monday February 7th. Also enclosed is a copy of the Soil Analysis Report. A sewerage flow rate of 50 GPD per 1,000 sq. ft. was used for the 2,688 sq. ft. convenient store for a total daily flow rate of 135 GPD. However, Title 5 requires a minimum allowable flow rate of 200 GPD for convenient stores. Therefore, a flow rate of 200 GPD was used to size the septic tank and SAS Field. The installed septic system consists of a 1,000 gallon septic tank, 1,000 gallon grease trap, D-Box and 1 —500 gallon leaching chamber with 4' of stone around the chamber. A vent pipe was installed during the installation process at your request. The existing septic tank and grease trap were field inspected and were found to be structurally sound and in good working condition and were re-used. The installed system meets Title 5 Standards. If you have any questions or need additional information please do not hesitate to call me. Sincerely, Robert A. Drake, P.E. 66 Greenville Drive Forestdale, MA 02644 Phone: 508-477-5048 Cell: 508-287-1253 E-mail: kcj528@msn.com i KCJ ENGINEERING ENVIRONMENTAL ENGINEERS SEPTIC SYSTEM DESIGN January 18, 2005 Mr. David Stanton,K5 wealth Inspector . Town,.of Rarnstable Publi--Health Division 200 Main Street TT 1 S_ /1 !A1 n yailais n / ,ivies. v/-vvl Dear Mr. Stanton: On behalf of the 7-Eleven Convenience Store located on#1149 Falmouth Road (Rniitc+ 2Rl in Ma T am ciihmittinrr to crnii (71 cicrnat] cite nlane fnr the aforementioned address for a septic system upgrade for your approval. The existing c veriienre store is approximately 2,658 square feet. There:is only are private restroo and there are no public restroon s on site. There is no cooking of foods at this convenience store. A sewerage flow rate of 50 GPD per 1,000 sq.ft. was used for sewerage flow calculations for a total of 135 GPD. However. Title 5 reauires a minimum allowable flow rate of 200 GPD. Therefore, a flow rate of 200 GPD will be used to size the septic tank and SAS Field; The proposed septic system-will consist of an existing- 1�5000 gallon septic,taroks an existing i,000gaiion grease trap, a D-Box and i —500 gallon leaching chamber with 4' of stone around the chambers. It is my professional opinion that the 1,000 gallon septic tank has more than enough capacity for this site. In fact it has over 5 days of capacity. The existing septic tank and grease trap were field inspect and were found to be structurally sound and Ill. good workang,condition. The preposed_system meets Title 5 Standards: Your timcly rcvicw of this matter is greatly appreciated. If you have any questions or need additional information please do not hesitate to call me. Sincerely, n L —4. A T-% -I,- n L \1VUVl L A. IJIUKC,1 .1.i. 66 Greenville Drive Forestdale, MA 02644 Phone: 508-477-5048 Cell: 508-287-1253 E-mail: kcj528@msn.com LOCATION PERMIT NO. VILLAGE INSTALLER'S AME i 1fES5 BUILDER 0R OWNER DATE PERMIT ISSUED ��- l_ f3 DATE COMPLIANCE ISSUED 11, C All/ G �r 20' it-so t.. f e TOWN OF BARNSTABLE aoos --c�44 LOCATION 114c)- E-a-rn©t1&b ✓CrAd SEWAGE �39 - 95 cot4 VILLAGE ��r�` ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. izo ba�-t u-.Y- SEPTIC TANK CAPACITY 1 C00 Coo «t-n LEACHING FACILITY: (type) 500 (size) NO.OF BEDROOMS (D C,e J`t l�2 F70J ro kq BUILDER OR OWNER PERMTTDATE: I 05 COMPLIANCE DATE: 3 ' Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by O �' 1 6#7T N cb� Fwl) MOT _ - ca r } i q�g `. V Bellaire, Dianna From: muhammad noor <thehncorp786@gmail.com> Sent: Friday, July 09, 2021 1:53 PM To: Bellaire, Dianna; Soto, Kathryn Subject: Sushi Centerville Hi, i have sent few emails to you guys. The equipment that is being used is only RICE COOKER to cook rice in and thats about it. Vegetables come fresh every day. Fresh rice everyday Soy sauce and condiments are pre packaged bought from restaurant depot. i 4-D ov C14" Atjc�'fi" LO vi -le �� _i �, .� �--F ��. .,r Process Flow Diagram of Sushi Receiving Ingredients:Rice,frozen fish meat,salt,sugar,vegetables Storage Store material in approved area and 6 inches above the floor. Dry storage of rice Cold storage of vegetables at below Frozen storage of fish meat at 5°F degree Celsius 41°F Preparation Assemble all ingredients and utensils.Weight and measure all the ingredients according to recipe. -7 Vinegar Solution Rice cooking-CCPi • Measure and mix vinegar,salt and sugar • Pre-soaking of rice in colander for 2hrs in refrigeration below 41°F. qHeat the mixture to dissolve salt and sugar t • Measure rice and water • Cook rice in rice cooker for 30min Acidification-CCP2 • Add 5%solution of vinegar to cooked'rice and mix with paddle and check it pH by calibrated pH meter.It must be less than.or equal to 4.1.if pH is more.4.2 then add more vinegar and again check pH if still more than 4.1`then discard the rice and remake starting with preparations Thawing of fish=-CCP3' Defreeze frozen fish under controlled environment below 41°F Assembly of acidified rice,fish,vegetable Rolled rice slurry around the other ingredients and cut into pieces Cold hold/Packaging-CCP4 Rolled rice slurry around the other ingredients and cut into pieces and packed into plastic and stored at 41°F and use within 72trs HACCP Risk Assessment City/Town of: Establishment Name Ingredients Source Address Person-in-Charge Information for the Risk Assessment was obtained by: ❑Observation of Suspect Food/Process ❑Observation of General Food Handling and Sanitation Practices ❑ Interview with Food Employee Responsible for Preparing Implicated Food. ❑ Interview with Person-in-Charge or Other Employee WeightlVolume of Suspect Food Prepared or Served: Dates of Investigation: PLEASE PRINT CLEARLY Describe Product Flow Describe Environmental Data Collected to Verify HAZARDS Describe Corrective and Preventive'Measures, Date . Control or Lack"of Control of Hazards -Contamination initiated Verified (Preparation Steps) -Survival -Pr©Ilferation (Include changes-infood`handling procedures,orders Who,What,Where,When: for correction embargoes/disposals,food employee' restrictions,food safety training,emergency_ suspensions and closures;etc.) ❑CCP (Critical Control Point) ❑CCP ❑CCP Page: Number—of HACCP Risk Assessment Report Form(Updated 09/05) ❑CCP Page: Number—of HACC"Usk Assessment Report Form(Updated 09105) Describe Product Flow Describe Environmental Data Collected to Verify HAZARDS Describe Corrective and Preventive Measures Date Control or Lack of Control of Hazards,. -Contamination Initiated 2 Verified (Preparation Steps) -Survival -Proliferation (Include changes:in food handling procedures,orders for Who,What,Where,When correction,embargoes/disposals,food employee - restrictions,food safety training,emergency suspensions and closures,etc.) ❑CCP ❑CCP ❑CCP ❑CCP ❑CCP ❑CCP ❑CCP Comments: Page: Number—of HACCP Risk Assessment Report Forth(Updated 09/05) How to Make Sushi Step by Step. Nori Nori is a type of seaweed, and you can get sheets of roasted nori in most Asian markets and specialty food shops, such as Whole Foods. Sushi Fillings Common ingredients include raw fish salmon, tuna, crab, tempura, avocado, cucumber and carrots. Ingredients • 3 cups sushi rice. • 2.5 cups water. • 1/4 cups anew rice inegar • 2 tablespoons ar • 1 teaspoon sAll vinegar is additive to sushi rice and also preserves the rice. Preparing Sushi rice and hold it at room temperature must take additional measures to ensure safety to those that consume it. Sushi rice is traditionally made by cooking the rice then adding vinegar. The vinegar acidifies the rice, lowering the pH. If the pH is maintained below 4.6, the rice is considered non- potentially hazardous. 1 .Prep the Rice & Nori Lay out the nori on the bamboo mat. Feel the nori; there should be a rough side and a smooth side. Make sure that the rough side is facing up. 2.Spread the Rice on the Nori Use your fingers to carefully spread the rice out over the nori. You want the rice to be spread out so that it looks nice and lacy, with some nori showing through the rice. 3.Add Fillings to the Bottom Quarter of the Nori Make sure not go over the bottom quarter! Otherwise, it will be hard to roll. 4.Roll the Sushi Part Way Next, carefully roll the sushi so that the end piece of the nori, rice, and ingredients curve over so that you have a shape that looks almost like a snail. 5.Move to Cutting Board Remove the mat and place the roll on a cutting board. 6.Cut the Sushi Using a very sharp knife, cut it into rounds. Make sure to clean the blade of the knife after every time you cut off a piece of sushi. The blade will quickly become sticky, so if you don't clean it, the sushi will be very difficult to cut. 7.Serve Arrange on a plate and pack it in a container. Measurement of Rice Being cooked in the rice maker. As our rice cooker capacity is only 3 cups. 1 cup = 8oz To cook 3 cups (24oz ) of Rice in a cooker. place the washed rice in the inner pan and add cold water. if 3 cups of rice are used the water should be 2.5 cups (20oz) used in it. place the inner pan in the cooker. plug the power supply cord and press the cooking switch down. the cooking lamp will light indicating that the rice is being cooked. DO NOT OPEN THE LID DURING THE COOKING PROCESS. When the cooking has completed, the switch will pop up. the cooking lamp will turn off and keep warm lamp will light to indicate the `keep warm' function is operating. Then the cooling time starts which should be at least 80 minutes. Once the rice has cooled enough but still warm, run a spatula through the rice using right and left slicing motions to separate the grains. Slowly add about 32 oz. vinegar mixture making sure all rice is evenly coated with the vinegar mixture so that all rice reaches the appropriate pH (less or equal to 4.1 U. The maximum product depth in the pan should not exceed 3 inches. The pH will be tested within 30 minutes after acidification of the cooked rice using a calibrated pH probe. More vinegar mixture may be added if target pH is not reached. Y. unplug the cooker after use, by first disconnecting the cord from the wall outlet. Prep Time: 5 minutes Cook Time: 30 minutes Resting/Cooling Time: 1 hour 20 minutes u r� HEAD OFFICE 7101 EAST SLAUSON AVENUE,LOS ANGELES,CA 90040-3622 P.O.BOX 875349 TERMINAL ANNEX,LOS ANGELES,CA 90087-0449 TEL. (323)721-6100 FAX.(323)721-6133 July 15, 2021 SK Mart Inc—Centerville Food 1149 Falmouth Rd Centerville,MA 02632 Dear our valued customer: This is to certify that JFC International Inc. is in compliance with the US Code of Federal Regulation 21 Part 123. We file certificates of compliance of seafood products from domestic and overseas' facilities that can provide documentation to verify their compliance with the HACCP Regulations.We are not processing the products at JFC. Frozen seafood products that have had parasite destruction were stored at-4°F or lower for more than seven consecutive days or were fully cooked at the vendor's processing plant prior to JFC receipt. Parasite destruction seafood products (amongst the purchased items) will be listed on the last page of our sales invoice. At the receiving stage of a frozen seafood products, temperature is taken by a hand-held thermometer which is calibrated regularly.A continuous monitoring and recording of the storage temperature is done with a verification practices in place. Receiving, storage and calibration logs are kept for a record keeping purpose. We will Not be sending Any fish related products to SK Mart inc DBA Centerville Food Mart Unless the Parasite destruction has been Done. If you have any questions, please contact us at 1-800-633-1004 Sincerely, Hidetaka Iinuma Vice President General Manager of Marketing Planning Division Manager of Quality Control Department SAN FRANCISCO LOSANGELES• HOUSTON•CHICAGO•NEW YORK•BALTIMORE•ATLANTA•MIAMI•SEATTLE•DENVER•HAWAII C { Rice Cookers > Rice Cooker/Steamer NHS-06/10/18 V Rice Cooker / Steamer NHS-06/10/18 q -' '� ea' "� ?fit�.�,. �' o rn .vim t� ,� � /G^✓'a"''a � '. ''�` ^�+.' :a t.�. s *ate , P � 41, •busas1rr.re•s•^�" �. , d 2*1WSH) KEEP WARM 1« ewo COOKIW CM —COOKING M 01 d .vNe.µea. iy :• N The Rice Cooker/Steamer features an easy-to-use single switch control and see-through glass lid with a stay cool knob.Stainless steel steaming tray and automatic keep warm function available on NHS-10(6 cups)and NHS-18(10 cups)models. SHOP NOW • Easy-to-use single switch control • See-through glass lid with stay cool knob • Stay cool handles for easy transport • Durable nonstick inner cooking pan • Stainless steel steaming tray and automatic keep warm function on NHS-10 R NHS-18 models only • UL listed • Instruction manual in English r 1/3 0 9 Easy-to-use single switch control Conventional rice cooker automatically cooks the rice and turns off when the rice is done {j1 FF S WONIN@ ` .fitt k H lld I1L�ii Automatic keep warm system keeps rice tasting fresh for hours ' ° See through glass lid with stay cool knob(salmon being steamed over cooking rice) . 4, rX l . : s Accessories include rice measuring cup,nonstick rice spatula and steaming tray(only for NHS-10/18) Model No. NHS-06 Capacity' Up to 3 cups 10.6 liter Dimensions(W x D x H) 9-1/8 x 7-1/2 x 7-1/2 inches Electrical Rating 120 volts 1300 watts Color White(-WB) Model No. NHS-10 Capacity' Up to 6 cups/1.2 liters Dimensions(W x D x H) 10-1/8 x 8-7/8 x 8-7/8 inches Electrical Rating 120 volts/500 watts Color White(-WB) Model No. NHS-18 Capacity" Up to 10 cups/1.8 liters Dimensions(W x D x H) 12-5/8 x 10-3/4 x 9-3/8 inches Electrical Rating 120 volts/600 watts Color White(-WB) 'Capacity is measured in the approx.6 oz./180mL rice measuring cup,using raw short grain white rice.Other grains may vary. 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'` T ,�'� . .+h'x` �' .� '• a,m _� " v� ." °mot *m*;, y"%A •T elmw;µ '- l a+.? '`x 7 Nk" •"",it*+'"a1*&s"�ya' @ .1` q`kso-t ^e' ..F.r, ai y �c ., ." ^aa+•a�$%5t ._,. �8" » '; ``"';- `° ''� ��+xt vk» ry .-;a, °'.`xt�" i�' `'T a '3"r t �,`�w �'��mp�`r' �'x, *'u•s>r.a '� y � � ,,:�,�,, ,x$»= t„�:� €�, F y;.Fa •,.� 'xwa TM� f' +u�g�t �'' »'� m. ':�' '' r, ,_ "' ',,, "."" °* .: •, !,t'sa:.r .;has, "S s�' s:':"`+y-� �_�d? r ;y�x'F �c+ ;ue ., .„: ,.^y Aw Y� k � �,:,, e ��>^baa•>.: ..��, �' -�,: " Mom.:,�+ ,� r» t V ' - - HACCP Critical COntr-I'Mnts Monitoring Procedure Hazards Critical Limits for each Correction Corrective Action Verification Records NO. Critical Control Point(CCP) (Physical,Chemical,Biological) Control Measures COP What How When Who Calibration of Biological-Presence of Cooking to kill Check the internal Head thermometers to be Check thermometer cooking Cook until 167'F for at least 15 1 Cooking of Rice At least 167'F Stem thermometer Each batch Chef/supervisor seconds done on daily basis calibration log,cooking time/temperature log, vegetative bacteria in raw food bacterial growth temperature of food of the kitchen Re-Train team on SOP's time/temperature log daily caliberation log ph meter/pH test check If pH is above 4.2,add more Measure pH of each Check recipe and Check sushi rice pH log and Rice pH log and pH 2 Rice Acidification Biological-spore forming Maintain acidic pH batch 15 minutes Sushi chef strips record pH of vinegar solution and measure again. Rice pH 5 4.1 pH of rice production procedure pH meter caliberation log meter caliberation log, bacteria(Bacillus cereus) of rice each batch on sushi after preparation If pH is above 4.2 again,discard and prevent future correction daily training record rice log sheet start over. Evaluate the training on SOP's Thawing under Controlled time& Thawing high risk Record the starting Discard an meat item left in danger Review the function Check thawing Thawing 3 Thawing of Fish Vegetative bacterial growth temperature, frozen foods at 41"F Thawing time and time&end time for Each batch Sushi chef y g temperature zone for more than 4 hours sheet and evaluate the time/temperature log daily time/temperature log monitored& ,use within 48 hours the process actual Quantity required recorded to be thawed. Check the Review the preventive temperature of food maintenance schedule Cold food at 41'F,Hot Discard food if critical limits for cold for holdingunits Check time/temperature log Monitoring Check the with stem After Eve 2 hours Sushi chef food is not met for more than 4 Time/temperature log 4 Cold Hold/Serve Vegetative bacterial growth Temperature control food at or above 140-F temperature of food thermometer with Every daily for 4 hours interval of maximum hours for cold&2 hours for hot food Review monitoring two hours methods&frequency I � 1 r r F NO. Critical Control Point Hazards Control Measures Critical Limits for each (CCP) (Physical,Chemical,Biological) CCP What 1 Cooking of Rice Biological- Presence of Cooking to kill At least 167'F Check the internal vegetative bacteria in raw food bacterial growth temperature of food Biological-spore forming Maintain acidic pH 2 Rice Acidification Rice pH <_4.1 pH of rice bacteria (Bacillus cereus) of rice Thawing under Controlled time & Thawing high risk Thawing time and 3 Thawing of Fish Vegetative bacterial growth temperature, frozen foods at 41'F monitored & , use within 48 hours temperature recorded 1 Monitoring Cold food at 41°F, Hot Check the 4 Cold Hold/Serve Vegetative bacterial growth food at or above 140'F Temperature control temperature of food for 4 hours 2 "HA((,P Critical Control'Points t Monitoring Procedure, Correction Corrective Action How When Who Calibration of Head Cook until 167*F for at least 15 thermometers to be Stem thermometer Each batch Chef/supervisor seconds done on daily basis of the kitchen Re-Train team on SOP's ph meter/pH test Measure pH of each check If pH is above 4.2, add more Check recipe and strips record pH of batch 15 minutes Sushi chef vinegar solution and measure again. production procedure each batch on sushi after preparation If pH is above 4.2 again, discard and prevent future correction rice log sheet start over. Evaluate the training on SOP's Record the starting Discard any meat item left in danger Review the function time &end time for Each batch Sushi chef zone for more than 4 hours sheet and evaluate the the process actual quantity required to be thawed. 3 Check the Review the preventive temperature of food Discard food if critical limits for cold maintenance schedule with stem After Every 2 hours Sushi chef food is not met for more than 4 for holding units thermometer with hours for cold & 2 hours for hot interval of maximum food Review monitoring two hours methods&frequency 4 Verification Records Check thermometer cooking calibration log, cooking time/temperature log, time/temperature log daily caliberation log Check sushi rice pH log and Rice pH log and pH pH meter caliberation log meter caliberation log, daily training record Check thawing Thawing time/temperature log daily time/temperature log 5 Check time/temperature log Time/temperature log daily 6 V Training Course Outline Date: Duration: Trainer Name: Learning Objectives Introduction to HACCP HACCP stands for Hazard Analysis Critical Control Point. It is a system where the food manufacturer or handler identifies the potential hazards that can be introduced while the food is in the production process or in the care of the organization, and determines how those hazards can be eliminated. Hazard Analysis Procedure Hazard analysis is defined as the process of collecting and interpreting information on hazards and conditions leading to their presence to decide which are significant for food safety, and should be addressed in the HACCP plan. ,/ CCP Identification procedure A CCP is defined as a point, step or procedure at which control can be applied and a food safety hazard can be prevented, eliminated, or reduced to acceptable levels. All significant hazards identified by the HACCP team during the hazard analysis must be addressed. CCP Monitoring procedure Monitoring is a plan which includes observations or measurements to assess whether the CCP is being met. It provides a record of the "flow of food" through the establishment. If monitoring indicates that the critical limits are not being met, then an action must be taken to bring the process back into control. Corrective Action procedure A Corrective Action procedure defines requirements for reviewing nonconformities; determining the cause of nonconformities; evaluating the need for action to ensure that nonconformities do not recur; determining and implementing action needed; updating documentation; recording the results Personal Health and Hygiene Personal hygiene is how you care for your body.This practice includes bathing, washing your hands, brushing your teeth, and more. Every day, you come into contact with millions of outside germs and viruses.They can linger on your body, and in some cases, they may make you sick. ,/ Proper Hand washing IPL Page 1 of 3 Controlled Wet your hands with clean, running water(warm or cold), turn off the tap, and apply soap. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds. Cleaning and sanitization Methods Cleaning removes food and other types of soil from a surface such as a countertop or plate. Sanitizing reduces the number of pathogens on that clean surface to safe levels. To be effective, cleaning and sanitizing must be a 4-step process. Surfaces must be cleaned, rinsed, sanitized, and allowed to air dry. Thermometer Calibration procedure Thermometers should be calibrated regularly to make sure the readings are correct. The ice-point method is the most widely used method to calibrate a thermometer. ./ Cross-contamination Prevention procedure Wash hands and surfaces often. Harmful bacteria can spread throughout the kitchen and get onto cutting boards, utensils, and counter tops.To prevent this: Wash hands with soap and hot water before and after handling food, and after using the bathroom J Use of pH meter or pH strips Paper test strips are convenient and have varied purposes. One purpose is to determine the acid content of substances by measuring the pH, or concentration of hydrogen ions.This type of paper contains a dye that changes color within a certain range of pH values. IPL Page 2 of 3 Controlled Signature: IPL Page 3 of 3 Controlled V/ Training Attendance Sheet —All Staff Date: 4-01-21 Duration: Trainer Name: Topics: Introduction to HACCP Hazard Analysis Procedure S. No Employee Name Designation Signature 1 2 3 4 5 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Signature: IPL Page 1 of 1 Controlled Doc.No.:LIST/IMS/14 Rev.Date: Version No.:14.1 ......__.... _._...._—..— Yearly Training Plan (All the Training Steps below will be Given before anyon anyone starts making sushi) This will be a yearly review j Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 CCP CCP Thermometer Introduction to Corrective Action Proper Hand Thermometer Caliberation Use of pH meter Introduction to Corrective Action Use of pH meter Indentifiwtion Indentificatio Proper Hand washingCaliberation HACCP procedure procedure washing - procedure or pH strips HACCP n procedure procedure - procedure or pH strips Cross- Cleaning and CCP All$tell Hazard Anlysis CCP Monitoring Personal Health and Crosstontamination Prevention Caliberation of Hazard Anlysis Personal Health Cleaning and sanitization. contamination Caliberation of sanitization Monitoring' Procedure procedure Hygiene procedure pH meter Procedure and Hygiene Methods Prevention pH meter Methods procedure_ procedure 1 � ---- —. ------- r—-- —T— --- —'-- I 13 j 16 17 ---...___.. _.._—__—._._—..._._�..__.._._........_... 19 j 20 __ _—_.—.—. —_--_...__....._....___...—_..._.._.____.__._....._.._�. 22 23 24 27 -- 28 29 I 30 32 j—. 33 --.___.____..._.__....._—..._..__..__.__...__.-.........._._...---- ...... --- 35 38 39 ........__._....40 _.._._ --. — 41 q 44 45 .—_._.—.._..__..... .--..___ --_—_ __— 48 49 50 IPL 1 of 1 Controlled Start Each Shift With: Daily Sanitation/Operation Log Date: 1. Hands Washed&A fully supplied hand washing station }} 2. Access to 200 ppm sanitizer k ,White Rice pH Measurement 3. Calibrated thermometer,pH meter&available log End Time pH Time PH pH Meter Time Initial 2n4Reading 4. Bamboo mats wrapped in plastic of Rice Measured Calibrated: Rice Is All if pH is>4.1 S. Healthy employees Cooked 7.0/4.0 Used Batch 1 Insert TIME in top column&INITIAL after each task is completed Batch 2 Daily Cleaning Batch 3 Equipment Start Time: 4 Hours: 4 Hours: End Time:4 Batch 4 Orderly;Clean and sanitize tables, Batch 5 countertops,sinks.Clean all work surfaces Batch 6 All utensils,cutting Lards,bamboo mats, pans properly cleaned&sanitized;proper Batch 7 concentration Personal health,hand washing practices, Record time rice is cooked.Rice pH is measured within 30 minutes after mixing&must be between 3.8-4.1 11 pH>4,1,add 8-12 oz.of vinegar,retake pH and record in the"2n°Reading^column,if pH>4,1 after addition,discard glove use,proper hair covering,no jewelry, Record time rice is used up or discarded clean and maintained outer arments --,,, All food dated,protected and labeled Brown/Quirtoa_/Multi-;grain Rice Cooling- ` properly Type of Time Rice Time Rice Time Rice Rice Discarded Initial Proper storage and labeling of chemicals and cleaning items Rice Reaches 135'F Reaches 70'F Reaches 41'F Yes/No Batch 1 Shelves,display rases,refrigerators and freezers clean,orderly&operating properly Batch 2 - Clean floor,drains&trash can, Step 1:DO NOT COVER WITH LID. Record the time rice cools to 135'F Step 2:Record the time rice cools from 135'F to70'.F(must be within 2 hours) remove trash Step 3:Record the time rice cools from 707 to 417(must be within 4 hours) Calibrate Thermometer Daily(32'F) 'Rice is discarded if cooling times in Steps 2 and 3 are not met (and if dropped or mishandled) Time: Initial: "Packaged Sushi Cooling(cool within 4 hours) Internal Temperature of Temp/Time Temp/Time Temp/Time #of Packages Time Start Time End Out Temp Discard Initial Food Morning Afternoon. Evening Yes/No -F Sushi Display Case -F 'F 'F •F Cold Top/Prep Cooler •F °F 'F 'F Reach-in Cooler 'F `F 'F °F Walk-in Cooler 'F 'F -F °F Freezer °F -F 'F "F Initials Calibrate thermometer daily,when dropped or mishandled in ice water until it reads 327,If it doesn't reach 32'F,notify your RM/RS for replacement Supervisor Signature: Date: corrective Action: Document Full Service Daily.5anitation/Operation Logbook Si\Compliance\Logbook\2014\Full Service Logbook Version:02/2019 Cleaning , sanitizing and disinfecting. If dishes, utensils, countertops, and equipment haven`t been properly cleaned and sanitized, they can spread dangerous pathogens to every food item they touch. Review the importance of cleaning and sanitizing with these simple steps. • 1. Scrape away leftover food on the dishes and utensils. 2. Clean the dishes and utensils in the first sink with soap and warm ; water. 3. Rinse the dishes and utensils in the second sink with clear, clean water. 4. Sanitize the dishes and utensils in a chemical solution or very hot water (at Feast 1710F) in the third sink. 5. Allow the dishes and utensils to air-dry. • How often should you clean and sanitize food contact surfaces? • Clean and sanitize a food contact surface after working with raw meat, when switching from one food to another,, when switching tasks, after taking a break, and after four hours of constant use. • 6.To disinfect your cutting board, use a fresh solution of 1'tablespoon, of unscented, liquid chlorine bleach per gallon of water. Flood the surface with the bleach solution and allow it to stand for several minutes. Rinse with water and air dry or pat dry with clean paper towels.. To promote proper cleaning and sanitizing, consider implementing the ; following ideas in your establishment • Teach employees to touch silverware only by the handle and to carry cups and glasses only by their bases, stems, or handles. Otherwise, employees could accidentally contaminate clean dishes. • Demonstrate how to mix sanitizing solution and how to check for proper sanitizer levels. If a mixture is too weak, it won't kill bacteria. Train employees to use a test strip to make sure the sanitizer is mixed correctly. • Train your employees to avoid spraying chemicals in areas where. food is being prepared. When chemicals are sprayed, they can become airborne and can settle on nearby surfaces and food. C(P -4:, THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IM A , DATA 7irrte, NbrId FOODS 22 30ad, Boston, MA 02118, Phon( o-'17) ;/6�+ 9988: Fax (617) 269,513U. i, david-�iAtruewori.Jfoods.com 17he euntro.1 of par�,.sftes h)2() Mall-i S-aect fivaiiins, NIA 0.2601 Ti-te. states that P41,151tes k:wv-.1J1eJ ,1;1 UnCOQke(i cfd t;tifood van health hazr d, i i: t5 -et:onullended to control thj,, wd i. fieezing L,.- y de.-grees Faihi--vh sir ,-,v i'Or 7 iays or degi cc-: or bclow I f()r 1 to 1-.-Tt the para,,iiv, "Nt. -,erti A; Lbat the p.,�)v ide you have m Fal {lie TDA reCO&MS Ilia! TALA CV�TV INj)k., 0.1. "AW fish poses a pariis,te h z rcl. A tab - of '4'ecles aliki associated :ks pw-)Ilstieu 1-ti the FDA's Fish a,� i fido�.ues Pioduct-S Il'i ,aids he C".)II1.1ol Gq'i I 'v COITUIX)Llly us. .1 Ir tiusM and which At Ut,f PO A, d PAM6 Itt "Id—'drd ai-e ihc b.: cliji, vellev,fin, and bigr:. -, nLn&", yellowlaIL sl.k, od.wr fish speclvb.. ivAd ;1�03i i -.a-ra of f4n I sed ;,sh (:hi i are fed `cad) 11 %—X.ni','V w.'i". the xr(-;; � au(i-raised tish w%,, ;w v ep fed vii."b f oFTNE, Town of Barnstable BARNSTABLE, ; Board of Health 9qj 1639. � 200 Main Street, Hyannis MA 02601 prFD 1�p Office: 508-790-6265 October 24, 2017 Public and Environmental Health Program Policies, Procedures, and Guidelines Administrative Approval of H.A.C.C.P. Plans No. 2017- 011 If a HACCP (Hazard Analysis and Critical Control Point) plan is required, as specified in Section 8- 201.13 of the 1999 Federal Food Code, this policy provides full authority to an agent of the Board of Health (it's Health Agent and/or a health inspector) to grant administrative approval of a proposed HACCP plan submitted by an applicant. Applicants may not be required to appear before the Board of Health at a regularly scheduled meeting of the Board in order to seek approval of a HACCP plan. However, nothing in this policy shall prohibit the Director of Public Health from requiring an applicant to appear before the Board of Health for a specialized processing method identified in Section 3-502.11 of the 1999 Federal Food Code, particularly when the HACCP plan is incomplete and/or fails to comply with the 1999 Federal Food Code or the State Sanitary Code, 105 CMR 590.000.. During the public hearing of the Board of Health, the Board may require an applicant to hire a certified HACCP Manager and/or other qualified food safety consultant to prepare the required HACCP plans. VOTED: June 14, 2011: Upon a motion duly made by Dr. Canniff, seconded by Mr. Sawayanagi, the Board unanimously voted to approve the proposal. Wayne Miller, M.D. Paul J. Canniff, D.M.D. Junichi Sawayanagi \\toa\depts\HEALTH\POLICIES\HACCP Plan Review.docx f -S�A jl .0,4,A�J� ak- dew t Sbfj l � r AMA LA W�4 � �nS cyl- �► L v 9 i i �. r _. . _. . �. __- �- r I • �. �, •.- - � . ___ . .. . _ . ___- F. _ . ____ . � . . _ '. �- __. ' _� l �- Soto, Kathryn From: Soto, Kathryn Sent: Thursday,July 15, 2021 9:22 AM To: 'muhammad noor' Subject: RE: Centerville food mart This should be the last of what I need: The vinegar is not mentioned very much, especially about the process with the rice. That needs to be detailed Need measurements for vinegar being used. How long is rice and vinegar sitting together? Is vinegar being used as a preservative or additive? Need information in writing showing rice being cooled,time for cooling and depth of the pan. It just says to the number 3 line (what is the depth in measurement) We need a letter from the fish supplier/warehouse you buy it at certifying the seafood products have been frozen to kill parasites. It should state that it has been frozen so many days. The conversion rates for measurements need to be fixed they are incorrect. Other than that it looks good. Get me all this and I will have the director review it for the final sign off From: muhammad noor [mailto:thehncorp786@gmail.com] Sent: Thursday, July 15, 2021 8:01 AM To: Soto, Kathryn Subject: Centerville food mart i Hey, good morning. Is there anything you need from me? Please let me know. Thank you CAUTION:This email originated from outside of the Town of Barnstable! Do not click Finks, open ' it address and know the content is safe! attachments or reply, unless you recognize the sender's email add pY g i i EVALUATION TOOL FOR ACIDIFIED RICE HACCP PLANS Last Updated 3116104 ❑ Standard Operating Procedures(SOP) Most recent inspection report indicates compliance with 105 CMR 590.000.Any pre-existing violations, which may result in biological,physical or chemical contamination of this product,have been corrected. ❑ SOP for pH measurement — Manufacturer specs and calibration instructions for pH meter or pH paper(.3 or less scale)used provided — Instruction for measuring pH of rice slurry made with distilled water provided — If a pH meter is used: ■ Buffer solution,which has not passed expiration date,used ■ 4.0 Buffer solution(unless manufacturer recommends otherwise)used ❑ Recipe/Formulation Provided "• — Strength of vinegar identified(%by volume) — Preparation steps identified — Recipe/formulation(target pH at or below 4.1)validated,signed and dated by a food laboratory ❑ Preparation Steps Identified ❑ Hazard Analysis Included Growth of B.cereus and production of toxins identified ❑ CCP Identified Acidifying step(addition of vinegar to rice) ❑ Critical Limit Identified pH of acidified rice must be tested prior to use. If using pH paper,the pH shall not exceed 4.3.If using a pH meter,the pH shall not exceed: ■ 4.3 if tested within 2 hours of preparation,or ■ 4.6 if tested after 2 hours of preparation. ❑ Monitoring Procedures Identified — Calibrated pH meter or pH papers used to measure each batch of acidified rice — Person(s)identified for testing pH of rice ❑ Corrective Actions and Documentation Procedures Identified If rice not tested,do not use until tested. If rice is above 4.6(or 4.3 using pH papers), — Discard if rice not made within the hour — If rice made within the hour,cool immediately or add additional vinegar,re-mix and re-test pH — Verify use of correct recipe and procedures — Verify calibration and proper use of ph meter or ph papers , ❑ Verification(Short Term/Long Term)Process Identified — pH meter calibrated daily when used — Monitoring records reviewed daily or as needed by PIC — Recipe/formulation(target pH at or below 4.1)validated,signed and dated by a food laboratory ■ lab validation updated annually or when recipe is modified, ■ when daily pH levels are consistently higher than the laboratory validated pH measurement — Signed and dated HACCP plan reviewed and modified at least annually or as needed by PIC. ❑ Records to be Maintained Identified — pH log for each batch of rice(sample page included)maintained for.30 days — Corrective actions recorded in log(sample page included) — Daily calibration log maintained for pH meter — Laboratory test results maintained for one year (Continued on Back) ❑ Employee Training Plan Documented(sample of training log provided) c.. — Employee Health and Hygiene — Cleaning and Sanitizing Procedures — Cross-contamination Prevention Procedures — Monitoring Procedures for Acidified Rice — Use of pH meter or pH papers — Corrective Actions — Recordkeeping Requirements I w Standard Operating Procedures for the Sushi Rice Process Cooking of Rice 1 . Wash rice in a large container with water for 3 - 5 minutes, and drain thoroughly. 2. Place rice into the rice cooker, and add water. - 3. Cover and start the cooking cycle. Making of Sushi Rice (Acidified Cooked Rice) 1 . Remove cooked rice from the rice cooker and empty it into a large food- grade pan with a depth of 2 to 3 inches. 2. Use a spoon with long handle to spread the cooked rice evenly over the bottom of the pan. 3. Add the vinegar mixture to the cooked rice in the pan. 4. Use the spoon to thoroughly mix the rice with the vinegar mixture. The maximum product depth in the pan should not exceed 3 inches. 5. Let stand for about 15 minutes for the rice to absorb the vinegar mixture. 6. Check for pH level. Perform corrective action as needed. 7. Empty the rice into a washed and sanitized rice holder for protected storage until being used for sushi production. 8. Discard all remaining sushi rice at the end of the day. Copyright©201 1 MD Consulting. All rights reserved. Reproduction of any portion of this document without written permission from MD Consulting is prohibited. Dragon Lite 6 (D) Proposed EQUIPMENT types, manufacturers, model numbers, locations, dimensions, performance capacities, and installation specifications; (E) Evidence that standard procedures that ensure compliance with the requirements of this Code are developed or are being developed; and (F) Other information that may be required by the REGULATORY AUTHORITY for the proper review of the proposed construction, conversion or modification, and procedures for operating a FOOD ESTABLISHMENT. 8-201.13 When a HACCP Plan is Required. (A) Before engaging in an activity that requires a HACCP PLAN, a PERMIT applicant or PERMIT HOLDER shall submit to the REGULATORY AUTHORITY for approval a pro',perly prepared HACCP PLAN as specified under § 8-201.14 and the relevant provisions of this Code if: (1) Submission of a HACCP PLAN is required according to LAW; (2) A VARIANCE is required as specified under Subparagraph 3-401.11(D)(4), § 3-502.11, or ¶4-204.110(B); (3) The REGULATORY AUTHORITY determines that a FOOD preparation or processing method requires a VARIANCE based on a plan submittal specified under § 8-201.12, an inspectional finding, or a VARIANCE request. (B) Before engaging in REDUCED OXYGEN PACKAGING without a VARIANCE as specified under§ 3-502.12, a PERMIT applicant or PERMIT HOLDER shall submit a properly prepared HACCP PLAN to the REGULATORY AUTHORITY. 8-201.14 CC— For a FOOD ESTABLISHMENT that is required under§ 8-201.13 to have a HACCP PLAN, the plan and specifications shall indicate: 201 (A) A categorization of the types Of TIME/TEMPERATURE CONTROL FOR SAFETY FOODS that are specified in the menu such as soups and sauces, salads, and bulk, solid FOODS such as MEAT roasts, or of other FOODS that are specified by the REGULATORY AUTHORITY;Pf (B) A flow diagram by specific FOOD or category type identifying CRITICAL CONTROL POINTS and providing information on the following: (1) Ingredients, materials, and EQUIPMENT used in the preparation of that FOOD, Pf and (2) Formulations or recipes that delineate methods and procedural control measures that address the FOOD safety concerns involved; Pf (C) FOOD EMPLOYEE and supervisory training plan that addresses the FOOD safety issues of concern; Pf (D) A statement of standard operating procedures for the plan under consideration including clearly identifying: (1) Each CRITICAL CONTROL POINT, Pf (2) The CRITICAL LIMITS for each CRITICAL CONTROL POINT, Pf (3) The method and frequency for monitoring and controlling each CRITICAL CONTROL POINT by the FOOD EMPLOYEE designated by the PERSON IN CHARGE,Pf (4" The method and frequency for the PERSON IN CHARGE to routinely verify that the FOOD EMPLOYEE is following standard operating procedures and monitoring CRITICAL CONTROL POINTS, Pf (5) Action t0 be taken by the PERSON IN CHARGE if the CRITICAL LIMITS for each CRITICAL CONTROL POINT are not met, Pf and (6) Records to be maintained by the PERSON IN CHARGE to demonstrate that the HACCP PLAN is properly operated and managed; Pf and 202 (E) Additional scientific data or other information, as required by the REGULATORY AUTHORITY, supporting the determination that FOOD safety is not compromised by the proposal.Pf Confidentiality 8-202.10 Trade Secrets. The REGULATORY AUTHORITY shall treat as confidential in accordance with LAW, information that meets the criteria specified in LAW for a trade secret and is contained on inspection report forms and in the plans and specifications submitted as specified under §§ 8-201.12 and 8-201.14. Construction 8-203.10 Preoperational Inspections. Inspection and Approval The REGULATORY AUTHORITY shall conduct one or more preoperational inspections to verify that the FOOD ESTABLISHMENT is constructed and equipped in accordance with the APPROVED plans and APPROVED modifications of those plans, has established standard operating procedures as specified under¶ 8-201.12(E), and is in compliance with LAW and this Code. 8-3 PERMIT TO OPERATE Subparts 8-301 Requirement 8-302 Application Procedure 8-303 Issuance 8-304 Conditions of Retention Requirement 8-301.11 Prerequisite for Operation. A PERSON may not Operate a FOOD ESTABLISHMENT without a valid PERMIT to operate issued by the REGULATORY AUTHORITY.Pf 203 7/30/2021 The Home Depot-Order Confirmation Order #WD77850405 Placed on: Jul 30, 2021 Billing Information Muhammad Latif 67 STARLIGHT DR MARSTONS MILLS MA 02648 Payment Method: VISA***8494 Item Price/Item MY Line Total ........................................ ............................................................................................. ............---......... Ship To Home (1 item) 67 STARLIGHT DR , MARSTONS MILLS, MA 02648 US Weight Sentinel Stanchion with 6.5 ft. Black Retractable $65.00 1 $65.00 Belt (2-Pack) $79.97 Saved 19% Expect it on Aug 06 Subtotal $65.00 Shipping FREE Sales Tax $4.06 Total $69.06 You Saved $14.97 Need help? Online Customer Support: Call 7 days a week: 1-800-430-3376 6 a.m.to 2 a.m. EST hftps://www.homedepot.com/mycheckout/thankyou?cartld=HF1 0001 5766130&orderld=WD77850405&inStore=true&fromReact=true 1/1 • `, Gd� € a � a3 = a� 1— 4", W '15 4;wse 'I'm w Qw- Ar 01 40 Ali a % ivF zg 1, � i ��' - ' is � k,�'p �', :Z�"y 3• ' 14 17 w RA C a 3 ro t � , i AL a. rx crc a _ A M ^'S, _ F Ag- IN e i° s �� � .. ilA' , r i own of -ndrnsta me Inspectional Services Department y MASS. i639. Public Health Division �fb M1d A 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO This Cease and Desist Order is issued to: Mr. Zahid Rashid Centerville Food Mart-' 1149 Falmouth Rd, Centerville, MA 02632 Date: 09-30-2019 CEASE AND DESIST ORDER Pursuant to the Commissioner of the Department of Public Health's Order dated September 24, 2019, the sale or display of vaping products is prohibited in Massachusetts. Centerville Food Mart is hereby ordered to immediately cease and desist the violation of the Commissioner of the Department of Public Health's Order. Centerville Food Mart violated the Commissioner of the Department of Public Health's Order by [agent shall check all that apply]: ❑ the undersigned witnessed the sale of vaping products by Centerville Food Mart A/ the undersigned witnessed the display of vaping products by Centerville Food Mart ❑ other, see the below narrative description,with any necessary additional pages attached: Operation in violation of this Cease and Desist Order is a violation of law and may result in the issuance of a $100.00 non-criminal ticket citation. Each day's failure to comply with an order shall constitute as a separate violation. Recurring violations of this nature may result in a show- cause hearing before the Board of Health for a determination as to whether the tobacco sales permit shall be suspended or revoked. Signed by: Date: t ! Name. As agent of[Department of Public Health/TOB] Cease an ejistrder Received by: Date: 1a o� 1 Name: On beha f Centerville Food Mart \\toa\dcpts\I IEALTI-I\TOBACCO\WP Files\Letters&Mcmos\Centerville Food Mart Cease and Desist 09-30-19.doc 4 i own of rsarnstaulie HARNSTABLEI Inspectional Services Department y MASS. .69. Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-46411 FAX: 508-790-6304 Thomas A. McKean,CHO This Cease and Desist Order is issued to: Mr. Zahid Rashid Centerville Food Mart, 1149 Falmouth Rd, Centerville, MA 02632 Date: 09-30-2019 CEASE AND DESIST ORDER Pursuant to the Commissioner of the Department of Public Health's Order dated September 24, 2019, the sale or display of vaping products is prohibited in Massachusetts. Centerville Food Mart is hereby ordered to immediately cease and desist the violation of the Commissioner of the Department of Public Health's Order. Centerville Food Mart violated the Commissioner of the Department of Public Health's Order by [agent shall check all that apply]: ❑ the undersigned witnessed the sale of vaping products by Centerville Food Mart A/ the undersigned witnessed the display of vaping prod-ucts by Centerville Food Mart ❑ other,see the below narrative description, with any necessary additional pages attached: Operation in violation of this Cease and Desist Order is a violation of law and may result in the issuance of a $100.00 non-criminal ticket citation. Each day's failure to comply with an order shall constitute as a separate violation. Recurring violations of this nature may result in a show- cause hearing before the Board of Health for a determination as to whether the tobacco sales permit shall be suspended or revoked. r Signed by: Date: t 1 Name. As agent of[Department of Public Health/TOB] Cease a d esis rder Received by: Date: 10 Name: On behalf of Centerville Food Mart \\toa\depts\I 11 ALTH\TOBACCO\WP Files\Letters&Mcmos\Centerville Food,Mart Cease and Desist 09-30-19.doc No...........7........... Fxx.....��............... � LTH THE BOARD A® OFHEALTH 5 ----------- F............ .. ! .._...........-..A. a 2q Appliration for Disposal Works Tonstrurtion Vnmff Application is hereby made for a Permit to Construct (/-5,"or Repair ( ) an Individual Sewage Disposal S st t P . ..y . . - 1 : ...G .o r .. � ......1- ................... .�. -. Location- dress or L No. . ..... ... .. .. .. .:.....-•------- ,� 1 G.l.. � .9_T- W. _...... O er r Ad ess 3G ................................•--....__.................................... Installer Address � - 3 d Type of Building/ - _ ,,,� �U`�z Size Lot.................... .....Sq. feet U Dwelling—No. of Bedrooms.p. xpansion Attic ( ) Garbage Grinder ( ) �- P-1 Other Type of Building A sti' of persons............... ......... Showers ( ) — Cafeteria ( ) 'r Other fixtures ..--- W Design Flow....�.�- g.`.._. ._ gallo er person per day. Total daily flow................. �__ ._....gallons. WSeptic Tank Liquid capacity�'?�'gal'lor;s""length________________ Width................ Diameter................ Depth............... x Disposal Trench—No.---------_----_--- Width.................... Total Length.................... Total leaching area........._..........sq. ft. Seepage Pit No......-7......... Diameter.................... Depth below.mnie ....._........... To al lea ing area..................sq. ft. Z Other Distribution box (k1 Dosing tank ( ) d� �G i Z/;z�y, Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ................ ....I ...............7.. ......• O Description of Soil------.0......= Q' � �... .!2.-... r�y --a-r-------•it...... ...... ... ... x W ----------- •--•---••--•......-----••-•-•-----•--•••-••---•--•--------•-----••-••----•--•-........---•----•--•------------•---•---•--------••------•.......-•---••-•---•............•-------•-----•-- UNature of Repairs or Alterations—Answer when applicable._.............................................................................................. Agreement:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by th board�Itn. Signe .."�!.---.. . ...... ... .. ..---•-••-•---•-•--•-- ................................ pate Application Approved By--- = Y----------------•. : 22,(-7_�/.--------- / ----------- Date Application Disapproved for the following reasons---------------------------------------------•-•=---.....----.....------.............--•-••---•--•-•------••----- ....................................................................................•---..............---.......................... ............ .. ---------Date ...--------- Permit No......................................................... Issued...' . G Date -------- No........ -------• Kim....J.... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratio t for Uhipasal Works Cnl nstrurtion amit A . Application'is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal Syst t aLocation- dress or No. ..... Y............... .... 1. ... � P '- ........ t er Address W F- ' Installer Address Type of Build-rjg, iwh tl� �»' ---------... `---- +1� � � --� --�---�;--------- XPa Size-Lot................ =-Sq. feet DwellingNo. of Bedrooms. nsion 'Attic ( • ) Garbage Grinder ( ) Othe' T e of Buildin of ersons..............__7 Showers a YP Building-,,'.. P . . ( ) — Cafeteria 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 inle, ....._ _.......... To al lea ing area..................sq. ft. Z Other Distribution box (e) Dosing tank Percolation Test.Results' Performed by....--------------------------------------•----•-•-----•---------••---_.--- Date a Test Pit No. 1................minutes per inch Depth of.Test Pit....................... Depth to ground water........................ f� /'Test Pit No. 2................Imnutesper inch, Depth,of,Test Pit_;.................. Depth to ground water-,........................ t - --- -- rr j , Description of Soil. ! �'""+ + ._. _, ---- 9r ......_ _. W U Nature of Repairs or'Alterations—Answ,er lwhen applicable:........................................... .....--------------------------------------- .------- r Nei' Agreement: ;.�f•: The undersigned agrees to install the'aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanita> ; ode— The undersigned further agrees not to lace the system in P Y � , g g P Y operation until a Certificate of Compliance has bie&, issued by tN board f health. Signed 'f+r ...--••---•------------ ate Application Approved BY ;r- Date Application Disapproved for the following reasons:. ------------------------------------•--------------------•-•-••-•---•----•-------•--. .......................... -----------------------•------- •- -------, -••---•-•------•---------------------•---------------••--•---- ___----------- Date PermitNo........=................................................ Issued........................ ................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....O F.......... .. ...... .. ................... Trrtifira#r of Tompliana ,, HIaall"�', TO CE� FY, hatythe Individual Sewage Disposal System constructed ( ) or Repaired (x ' by. ..... • -•-•• _... ••-•••-• ' Inst er � � has been installed in accordance with the provisions of Article XI of The S to Sanitary Code as de cribed in the application for Disposal Works Construction Permit No..........,�_�_•-______-_-_------ dated.....*/A A:12y................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE'CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . . No. .... FEE.../ .......... r Permission is hereby granted ...._ to Const or' epai ( ) n Individl wag D' posh t S . tem at Street as shown on the application ication for Disposal Works Construction Per No______ _________ Dated.__,eZ � � �____....... w • ...... .. .........................� Board of Health /' DATE.; ......................... FORM .'1255,-•;HO$BS-&"WARREN, INC.,,PUBLISHERS - ,-." -11 - er f :,,I 11 4%1 . i - -,4.-., ­­ , .,, . _ . ;t -.1 �.;_11- . ,I-, _� I I I � .. . , # . - 1 _::_.____4 ,,- -. , * - � -!_ ­'- ­ .�� "�,k�_, I 41 a : � . .�, , .� . I �1,i�,?%- . I ,?. , �, ,Z1,-,41- I �-L :k,, , . , . �, 'a" r"', A 0 i 4N a'-' :�, 1, --i� !._�, , ,.11 1,� �� I '..;, f, " ,# .J­ 1. ��',, �, ,-A !", , . �, , , "" , ..," . � "" n .�,,, , . I " .-AWs- , ," "- , I W�;.� , I 1 r � I I � I lfv. � ­ I 0 , , �, 01 , - " ,"4 5 ym cy YU 0— a 0 ;_� - - V-, 11 � ,,>1 4 I c� sk An , -q -1, , ,, ,04,, , I " m '. I - A - -- -- , 0. 0"! 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I .. , ov, -0 , -�! � - � 4. . - "I - , - I . , :L �•I ,",�,-,- �A 0 1 � No..qj THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Uhiposal Worka Tons rurtinn Fautit Application is hereby made for a Permit to Construct ( ) or Repair (Qc� an Individual Sewage Disposal System at: /ODD GcJ�s� ,ilvy�inls7 G'�1JlGC4 ......_.. __....- -• --........ .................. ............•----...._..•--•--......----------•--••••-......--•--•---•--........................_. or Lot No. E!i..... ...... .. ....... a C�N/ O..ner Address . VType of Building ._..... Installer........ SAderess Lot �� �L?�_Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria Ga Other fixtures ----- W Design Flow............................................gallons per person per day. Total daily flow.........._........__....__...........__....gallons. f: Septic Tank—Liquid capacity�Q.gallons Length................ Width................ Diameter..._............ Depth................ Disposal Trench—No_____________-------- Vidth.................... Total Length.............._.... Total leaching area....................sq. ft. Seepage Pit No...........3..... 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--_________-_-_-._--_-- r3� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -----------------------------------•---------------------------•.....----•------•---._...._.._•-•_._......................................................... 0 Description of Soil........................................................................................................................................................................ x V W - ----- ------------------------------------------------------------------------ -------------------------------------------------------=----•--------------------............---------._..._.._-•-•-- V Nature of Repairs or Alterations—Answer when applicable.--__,_ 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 Compliant s been issuedby the board of health. Signed--- --- -- %.. - . ... --- --- -------------- ------- jam --- Application Approved B Application Disapproved for the following reasons: ........... . ..- .---------------------------------.................-----------......------.----.----------- ---------- ----------------------- --... --------X ------ ------------------ /? ..........I ------------------------ --------- --------- Date Permit No. Issued L No.....1. ....... r FEB» .»............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tomitrnrtinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: C,,4 _ ��. ............... ..Lo7tion Address '4 ; 3mi �U/7" /DDC --.._.....•-•••-.....4.--••-.---• --------•----•......-•--------------- --------------------- .. Owner Address te ��vsr -----....---•-----•••• •--•••--•---••- ------------------------------------•--••-.....-----....... ....------•-•--------•---•••....... Installer Address d Type of Building Size Lot._._.uG��.Sq. feet 2t- U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ............................ No. of peisons............................ Showers — Cafeteria QI Other fixtures ----------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitylOgallons Length................ Width................ Diameter................ Depth................ ` x Disposal Trench—No..................... Width.............._..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...........Z..... 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--___-___-___-__- Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ ---•----------------------------------------------------------------------------•---•--.........-•- --•--------------................. ----------------------- ODescription of Soil........................................................................................................................................................................ x V ...------•-----•--••---...•-----------••••-•---••••...-•-------------------------------------••-----------•------------------------•---......._....------------------....._..._.._...------......_..---- W ---------•-----------------------------------------------------------•-----••-. -•-•-------------------------------------------•--------•---------..._......._....------........._..................-- UNature of Repairs or Alterations—Answer when applicable____„ AV0e)e.__.. .................................................. . /. r4L' ---.... .. iTS SUl1 c1�JJn/J)ED...-•---•'a ...-Is U�l ........................ 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 Compliance- -as been issue0y the board of health. Signed ..- ------._------------------------- ---- �?;.... ...��� Application Approved By ... . Z1 ....vv.� ��..= 'l r Application Disapproved for the following reasons: .............................................. ........----........ ------ .................................................. ............ ...........::..................................................................`'...----..R.........................:...�. ........I ...................<.................... Permit No. 1.. .. ..... ..........-- ; Issued / / /-�'I-.�-----------D�-------- �� v Deer r THE COMMONWEALTH OF MASSACHUSETTS .., BOARD OF HEALTH TOWN OF BARNSTABLE gextifi ate of C autpliance THIS IS TO CERTIFY, That the Individual Sewa a Disposal System constructed ( ) or Repaired ( }�) b c / �Ll�y. ........ y4ru.57U ">® ........................................ .................... y .................................. . . .......... ... Insmlle, at ..................................................t ' t7 ...... ".------.....G�". ..* /1c....L... F.. has been installed in accordance with the provisions of TITLE 5 o T e State Environmental Code as desfribed in the application for Disposal Works Construction Permit No. ......Y.J- �-4'9 dated ........�........ l.. .......... PP P a-"w d-��--�- .� �...........r ' x-�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------- 1�.---'^1-1--LI J-----...--------...............-----------------.... Inspector ....... .... i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � -- TOWN OF BARNSTABLE No.�...�.-I......u;..;... � FEE..(.:? Disposal Works Tuntrnrtion Permit Permission is hereby granted. ! QlD ............ ._ � . dam to Construct ( ) or Repair (M an Individual Sewage Disposal System at No... 4_Ij t�Uc�S?� ,r/I/1.¢i�....�'��....... ----- ...Cf.1J���'��/ - ....... Street .......... as shown on the application for Disposal Works Construction Permit No..r..t._......._... Dated.:.. �_.�.. ..r_..A................. Boar .......... d of H alth�l �' ✓ ��._-7 _� DATE...................r_C.. `� r-•--...............--•---••---•---- FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS SEPTIC SYSTEM ANALYSIS Property location : 1000 West Main Street Barnstable, MA Owner Paul Lambert Prepared by: Down Cape Engineering 926 Main Street Yarmouth, MA 02675 �Fr a \� \� -`'j ` � �� � Current use of building as explained to us by the Lamberts, on december 17 , 1986. First floor : Existing retail space 45 ft x 90 ft =4050 sf 4050 sf x 5 gal/day/100 sf = 202 . 5 gal/day *Proposed fish market 28 . 5 ft x 13 ft =370. 5 sf 370 . 5 sf x 5 gal/day/100 sf = 18 . 5 gal/day Warehouse : 5 employees x 15 gal/day/emp = 75 gal/day Second floor Existing office 22 ft x 50 ft = 1100 sf 1100 sf x 75 gal/day/1000 sf = 82. 5 gal/day One bedroom apartment 110 gal/day TOTAL = 488.5 gal/day * Proposed fish market to be retail space only, no processing to be done on premises. V Future uses of existing building. First floor : Same as current use --- 296 gal/day Second floor : Entire second floor to be used as office (50 ft x 44 ft) + (70 x 30 ) = 4300 sf 4300 sf x 75 gal/day/1000 sf = 322.5 gal/day TOTAL = 618.5 gal/day CONCLUSION According to the information obtained from the Town of Barnstable Health Department (two 1000 gal septic tanks and the three leach pits ) and the flow estimates as determined by using Title Five of the Massachusetts State Environmental Code, the existing septic system appears to be adequate for the current and future uses as shown above. ya OF 4 ARNE H. y� OJALA 'i CIVIL No.30792 10 AL J r> APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS OCATION NO. P_ 3 58 7 ILLAGE _ DATE '?-/.?-,y -_ PPL*NT. sodT��,«.�a co/z!�• - FEE_ °� ' !7DRESS J3/ y ip� � a= v/�v�i��r/ iu�,����•�; TELEPHONE NO. (Non-refundable) NGINEER - /�v�t��.y4i✓.s / Gs� �G��.Q�,u ,�� .�•e e TELEPHONE NO. ATE SCHEDULED_ of (Applicant' s signature) O O U . . . . . . . . . . . . . . O O . . . O . . . . O . . . . . . SOIL LOG / UB-DIVISION NAME DATE %�Z]/ rC/ TIME r XPANSION AREA: YES NO _ _,PG"64el- OvIe ENGINEER OW1J WATER tAPRIVATE WELL _7 �S fie al3/ BOARD OF HEALTH EXCAVATOR KETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES : l - i FHL M O v -r H RD. r/f Zvotks , V \o /resT N � �� I�fS• 2.9, [;"RCOLATION RATE: 'ST HOLE NO: ELEVATION: /-/ , TEST HOLE NO: ELEVATION: 1 F_ _.--- 2 2 S 1a 1J D 5 _~_ S o Tel F 5 — 6 CRR Vr"L. 6 1i� L 12 12 13 13 14 14 15 __._...._._ 15 16 16 !.JITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD _LEACHING PITS LEACHING TRENCHES �ISUITABLE FOR SUB-SURFACE SEWAGE . REASONS: OTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION IRIGINAL: COMPLETED IN ENTIRETY BY P . E. AND RETURNED TO BOARD OF HEALTH 'SPY: RETAINED BY APPLICANT 03/09/05 WED 12:04 FAX 508 24i8t Robert B. Our Co. 9 003 • r` Town of Barnstable Regulatory Sere' ices . ' Thomas F.Geilgx,Director Public Health Dxvislarx �n Thomas McKean,Direotar 200 Matu Street,Hyazinis,MA 02601 Mee, 508-862.4644 ► ' r Fax, ;508-794-63Q4 .s Installer Zgafrmir Cerfification Form Date: Designer: Ynstaller: � Qc C< C G Address: _ Co Co -et)Vi I �� 1J1f Address: �Afe:E�r n CQ On C 6 (-I G was a issued ( ate) (installer} u pezxuit to install a U rn c '(WS—044 sepf�c system at � Fa � N.. (addzess -7777 .- gRe Da a desisn drawA .: �n 2: :dated (design*)_ ' l� I certify'that-the septic system r6weneed above was xnstal�d s•abstaxztially according to the desi a;whzah may iaei z approved changes such as lateral relocation, of the distribution box and/or septic tauk. pCAr,1s slaw new VeN7 oIpe WisgdJ1J • Per rC�ve�� aF IfPA�f� �9�•PN7 . I certify that the septic system referenced above was installed with major changes (i.e, greater than• 10' lateral"eloaation of the SAS or arty vertical relocation of any component Of the septic system)but in accordance with State•& Local Plan revigioR or certified as-built by designer to follow, xf,N F A44S o ROB�RTA. yG fC� ©� DRAKE CIVIL y No.41642 Uwtall er's 5`rgnat=) off'��0' STEPA�ccQ NA A o► � - l � (Designer's Sigpafure) (A.f ix Designer's'Stamp Here) _ . . ... I' EASE `To BAAl Ls r'A LE P- lamC .T1W MU M7ON �FRTIIZC TE C V11M Nab; sM..issUE� �3rTU �© 6 - G AS- BUH,'P CET7E11 B"LTECE B S F F, * C AI.' `H D1NStQ , LANK Q .1 Q:HellwSepat;/Dcsis3cr Certimoajj�Form I I Town of Barnstable P 4t �tttt Department of Regulatory Services 3 nara, • Public Health Division Date- 200 Main Street,Hyannis MA 02601 . M1g Date Scheduled Time Fee Pd. Foil Suitability Assessment for Sewage sposal Performed By. �cJ ( '"t `' EWinessed.By: LOCATION&/� ENERAL INFORMATION Location Address . 1 t l I r.rM uv gcX Owner's Name Address Assessor's Map/Parcel: .2 9-�G a -OU 2 Engineer's Name NEW CONSTRU(i PION REPAIR Telephone# Land Use (11,10M Slopes(%) / /d Surface Stones N� Distances from: Open Water Body ,11 ft Possible Wec Area � ft Drinking Water Well i� •a'ft Drainage way 101/1- ft. Property Line ft Other ft - SIOTCH:($treat name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I I I i i I _Y Parent material(gedlogic) dl7T� 1 Depth to Bedrock - Depth to Groundwater. Standing Water in Hole: Weeping from Pit FACE i Estimated Seasonal T1igh Groundwater DtMIATION FOR SEASONAL HIGH WATER TABL Method Used: �I Depth dbaerved standin in obs.hole: in. Depth td soll mottles" In. g; g. Depth toiweeping from side of obs.hole: Groundwater AdJustment index Weil#__.__^_ Reading Date: Index Well level --- AdI.faC .. -�- Adj.Oundwnter Leval i PERCOLATION TEST Date Thm Observation �6 ` Time at 9" Hole# Depth of Pere Time at 6" �art Pre-soak ime.CIO � 'lime(9"•6") St End Pre-soak 1 Rate MinAnch Site Suitability Assessment: Site Passed A Site Failed; Additional Testing Needed(Y/N) Original: Public He4lth Division Observation Hole Data To Be Completed on Back -- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable C4#servation Division at least one(I weik prior to beginning. Q:\SEPTICIPERCFURM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ! Cher Surface(in.) (USDA) (Munsell) Mottling (Strut Stones,Boulders. Cons ten Gravel) 9/ zo 7. . G 5 DEEP OBSERVATION HOLE LOG, Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis enc %Gravel) DEEP OBSERVATION HOLE LOG Hole# , Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi!en Gravel) DEEP OBSERVATION HOLE LOG Hole# — Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders• onsi m 1 Flood Insnrgake Rate Map: / Above 51DO year flood boundary No Yes --/-- within 500 year boundary No [thin 100 Year flood boundary No�. es w� Depth of N890M Occurrina Pervious Material exist in all areas observed throughout the Does at least fo feet of naturally occurring p7e2 area proposed fbr the soil absorption system? If not,what is the depth of naturally occurringaterial? Certification I certify that on. lfl (date)I have passed the soil evaluator examination approved by the Department of FM iron en 1 Protection and that the above analysis was performed by the consistent with the req "red training,expe ' and e ri nce described in 310 CMR 15.017 Signat J Date Q.%SEPTICWERCVORM.DOC r' i i LEACHING FIELD TOP OF FOUNDATION ELEV. = 100.6' GENERAL NOTES 1.) THE PROPOSED LEACHING FIELD SHALL CONSIST OF 1 - 500 GALLON, H-10 LEACHING CHAMBERS ' BENCH MARK CENTER OF RIM 1.) UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND RIM AT GRADE WITH 4' OF 3/4" - 1/2 DOUBLE WASHED STONE ON ALL SIDES. TANK RIM EL. = 99.2' +/- FINISHED GRADE OVER O CONSTRUCTION METHODS SHALL BE IN ACCORDANCE / DISTRIBUTION BOX = 99.1' +/- WITH TITLE 5 OF THE STATE ENVIRONMENTAL CODE AND ANY 2.) PLACE RISERS ON ALL CHAMBERS TO WITHIN 6" OF FINISHED GRADE. APPLICABLE LOCAL RULES. 9"MIN., 36"MAX, REMOVABLE COVER 5" DIA. OUTLET(S) 3" 36" AX. EXISTING 4" PIPE 3. THE GROUND ELEVTION AT THE LEACHING FIELD IS AT EL. =99.0 ' r CHEDUL 40 PVC ,s t ;'.. , � �� � 1 .,� , � � f � 011,91 2.) ANY CHANGES TO THIS PLAN -MUST BE APPROVED BY THE BOARD- -, _ w.A.. .+; MIN. SLOPE 0 2% THE ELEVATION AT THE TOP OF THE LEACHING FIELD IS AT EL. 96.03 + K.:;t - « }� / OF HEALTH AND THE DESIGN ENGINEER. PROVIDE WATERTIGHT = , THE ELEVATION AT THE BOTTOM OF THE. LEACHING FIELD IS AT EL. 93.20 ,,� �,,�, w � r. ..._-� !. . .,.zt, aC�: ,1 'A'.,>''" 3',T ,^.S Cf :; k t�` r'a g ,� F �{ 3j �, ,,: i>e '5 J ,f, :;m JOINTS TYP. r, � ,,,. '1.. . .,. .. .,;; '"'� ,:, '� r.�^� ,,, T... S �", „ « I .- mow.-.,, ...t.....: �.._, ... ._:: ., „ ...-., c. r. .: . „.. ,.. ,.. .. .,.. � ,.,....1.. ,- of>nW ,,.i e. .,,. Ja h k ......... d u. .. .+. .,.. ,+. c s.. . ..:. x.,. AT TEST PIT 1 GROUNDWATER .WAS NOT OBS V D `AT 7 0 w,_ r, � �. . .. _ , . ,, z . r ... l � ., s, .:F '�4ry .,, _ <. , p .< 3. 4 SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL 4 PVC IN FROM ,, .,...,. ,., .: v ..,r,. ,h _: y .., ,,,. �++ , . ,,,. ...�_, a, a ) d� „ .., �3 . ., I , " _. -. SEPTIC TANK GROUNDWATER WAS NOT REPORTED AT THIS ELEVATION DURING N .� , ,_ �� � ..,3-1 � PrG THE PERCOLATION TEST. ,. ,. ,N ,, ��,. u. �. r~ �, 97.a f 9ssz t �__.._.�__---.__._.___,_ a PVC our FROM LEACHING ,. -, s, .� G, � � �� w ,, ���, , ,.,. . � BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED, 5.57 f FACILITY. MINIMUM SLOPE 1% o s- ~a y t . AT THIS ELEVATION THERE S A MINIMUM OF 6.20 OF SEPARATION BETWEEN THE SAS SYSTEM .. � : ,� u� G,��7�.. :s. Y�? � N"sxu � „'.� s "� l � §'m,.: ya` .:.:.��r�x ; �;'• `" '`'a+ �� `�'t �t �I:: AND THE ,GROUNDWATER AS REPORTED DURING THE INTIAL SEPTIC I P TION` , . � _ x. t .,: OUTLET TEE 12 �- ss.3t NS EC Z{ ;, tt rr 4. 4 SCHEDULE 40 PVC PERORATED PVC PIPE SHALL BE USED 4 LIQUID LEVEL 95.5 t MIN. ,..,»b a ��i� i :� tt � �pE - 22 ZABEL FILTER 6" CRUSHED STONE ".tvYfn ti " INSIDE LEACHING TRENCHES OR LEACHING FIELDS, a'-a" t wq„ ., (GAS BAFFLE ON BOTTOM) $ t' OVER MECHANICALLY MINIMUM E , a�✓✓ 7 COMPACTED BASE ' , „ Y�' .��' �>;t, ,F ,�a:`W.,�. i, ., y,+,�'i.. � .. ,�:, x't 1 -6 .. .. ,s ? 1° wu �^ .s t 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 6" CRUSHED STONE 5 OUTLET DISTRIBUTION BOX (H-10) ------- -----s---------------. y .a.t,, ,., ) OVER MECHANICALLY TO BE RESET ON A LEVEL STABLE -- { � COMPACTED BASE BASE. FIRST TWO FEET OF OUTLET PIPES IT ,,, To BE LAID LEVEL, tiff n >* , s, t ;� ;;; �� 6.) THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. , --_---------'----- 4 , ,,.. � 7.) LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED CROSS SECTION VIEW 8 � „ a � �„ ,; x PRIOR TO BACKFILLING WHEN SYSTEM IS NEARLY COMPLETE AND EXISTING 1,000 GALLON CONCRETE SEPTIC TANK(H-10) .' --'� �� + , , G f �, .; ...� _:,� , , . :, ` rx i ;" READY FOR INSPECTION. SYSTEM IS NOT TO BE BACKFILLED ' ' , LENGTH 8.50 WIDTH 4.83 DEPTH 5.33 500 'GALLON R :, F�` DISTRIBUTION BOX DETAIL _ WITHOUT FIRST OBTAINING APPROVAL FROM THE BOARD OF HEALTH LEACHING TANK �12 10 N.T.S. AND DESIGN ENGINEER. SEPTIC TANK PROFILE N.T.S. $. ELEVATIONS BASED ON AN -ASSUMED ELEVATION OF 99.20' ON PROP. 4 PVC PIPE � .,♦x �. ��.. .I� h, *� `` � �w�r THE RIM OF THE SEPTIC TANK COVER AS SHOWN ON PLAN I �� �� z� ' DRAWN BY BAXTER & NYE INC. DATED 9-23-83. INV. EL, = 95,20 , S;,z�;#o,' LOCUS MAP 9.) CONTRACTOR SHALL VERIFY ALL :UTILITY LOCATIONS PRIOR TO N.T.S. CONSTRUCTION THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES TO THE DESIGN ENGINEER. APPROXIMATE GROUND ELEVATION = 99.00' -- --__ _- -- - --- - ------- --- - --- -- -- ------- ---- -- 10.) NON-SHRINK GROUT TO BE USED AT ALL POINTS WHERE PIPES AS-BUILT TIES _ _ _ PROVIDE 9 MIN. 36 MAX. APPROX. EL. 96.03 + ENTER OR ALL CONCRETE STRUCTURES IN TO R DE ---- i WATER TIGHT SEALS. 2 OF 1/8 , TO 1/2 7-c-, DIST. DIST. ELEV. ELEV. DOUBLE WASHED STONEf�" 11.) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE`WITH DEED PT. # DESCRIPTION PT. A PT. B IN OUT . ,� -J �' ;� lei 3/4" T0. 1-1/2" DOUBLE OR ZONING REGULATIONS, OWNER/APPLICANT IS TO OBTAIN SUCH 1 D-BOX 46.0' 33.0' 95.5' 95.3' WASHED `STONE TO. CROWN `� � r � 2'-10" DETERMINATION FROM APPROPRIATE AUTHORITY. OF PIPE c C C � 1 � 2'-oil _ 2 500 GAL. SAS TANK 43.5 46.0 95.2 r � 12.) ALL SEPTIC SYSTEM COMPONENTS INSTALLED UNDER A 3 SAS FIELD 44.0' 36.0' U� DRIVEWAY OR WITHIN 10' OF DRIVEWAY, SHALL WITHSTAND 2 - H-20 LOADING REQUIREMENTS. 4 SAS FIELD 42.0' 56.0' 4'-o" 4'-1 o" 4'-0" 13.) DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, 1 00 A TANK O , 5 ,0 GAL 38.9 22.5 96.0 95.7 � 12 10 APPROX. EL. = 93.20 + - .I DUST AND FINES. 6 4 VENT PIPE 47.2 8 I? p END VIEW N.T.S. V ALL LOAM SUBSOIL ( 14.) WHERE REQUIRED, CONTRACTOR SHALL REMOVE p► r - AND UNSUITABLE MATERIAL BELOW AND FOR AN AREA 5 FT. ON ALL >~ qy s SIDES OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL V pR _ , O APPROXIMATE GROUND ELEVATION = 99.00 +/ WITH CLEAN COARSE SAND FREE FROM CLAY, FINES OR OTHER $o a o _ . ----- ---- - ------ --_ -- - UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). P _ __ __ _ _ __ _ (Y� » !, 9" MIN. -36 MAX. �j 2 OF 1/8 TO 1/2 15.) CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES 243 DOUBLE WASHED STONE ; FOUND IN SITE CONDITIONS FROM THOSE SHOWN PRIOR TO ,� CONTINUATON' OF WORK. C� r - aoLret WASHED STONE ,_ 16.) PROPOSED PPpJECT IS LOCATED WITHIN: 2 10 'Tt�'CF?OVVN OF PIPE '._r .,,,_ . .. .�- �,-_r 2 -0 17.) THIS PLAN IS TO BE USED ONLY FOR SEPTIC SYSTEM UPGRADE. j KCJ ENGINEERING WILL NOT ASSUME ANY LIABILITY FOR �. USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. r f'� 0 r 18. CONTRACTOR SHALL BE REQUIRED TO ADD FILL AS SHOWN ON THIS f. _ S 16 6 �tov � � 13 DRAWING OR A5 REQUIRED. , , 0 PROFILE VIEW: LEACHING FIELD (N.T.S.) t� DESIGN DATA: t - TEST PIT DATA LEGEND 4 tyA ^�t CONVENIENCE STORE: 2,688 SQ.FT. J , M C \ - c DESIGN FLOW: 50 GPD PER 1,000 SQ.FT. EXISTING CONTOURS S �= - PERC. NO.: TEST PIT NO. 1 50 x 2.688 = 134.4 GPD 15 I� _�- O V 4` PROPOSED CONTOURS 0 _ . v 0�q et0 WITNESSED BY: DAVID STANTON. HEALTH AGENT USE MINIMUM ALLOWABLE FLOW - 200 GPD TP TEST PIT LOCATION LOT#3 PERFORMED -BY: DAVID B. MASON, R.S., C.S.E. SEPTIC TAN • o - o IT co klq� K. N y q DATE: 1-14-Q5 = - PROPOSED 500 GAL LEACHING CHAMBER H 10 - ..- 200 GAL X 200� 400 GALS. DEESIGN CAPACITY - ( ) O E , o �. O Q USE .'EXISTING 1000 GALLON SEPTIC -TANK I GROUND ELEV., 52.96 G �$ EE3 EXISTING 1,000 GAL SEPTIC TANK (H-10) / ` 1p8$ 5d1 EXISTING 1,000 GALLON SEPTIC TANK ELEV. WATER: > 12.0' BGs REQUIRED LEACHING AREA: „ 2� PT.y6 --'� TO REMAIN 4 SOLID SCHEDULE 40 PVC PIPE: PERC. RATE: 2 MIN. IN. „ EXISTING 3"SPLIT RAIL (200 GAL/DAY) / (0.74) - 270.3 SQ. FT. 4 PERFORATED SCHEDULE 40 PVC PIPE 00" FENCE TO REMAIN pT. ! 5 99.00' +/- SIDEWALL CAPACITY: � DISTRIBUTION BOX (H-10) `.:. - - 20' OFFSET FROM BLDG. - �Q�, � 1 FILL , - -/ _ 14" _- 97.83' , WI - 0 SQ. FT. 0 12.83 (LED H) X 2 0 0(HEIGHT) X 2 2 51.3 SQ. FT. EXISTING GREASE TANK EXISTING LEACHING PIT 20'! Ao - 10Y 4/3 97.33' TO REMAIN PUMPED AND FILLED R - -. TOTAL SIDEWALL CAPACLTfY = 117.3 SQ. FT. Bw - 1OY 7/4 NEW D-BOX - _ 4 6 �. APPROX. LOCATION � -__ 36 - __ ____ - 96.03 BOTTOM CAPACITY: REV. DATE APP DESCRIPTION EXIST.GAS MAIN 187.86 NEW 4"PVC PIPE AS-BUILT S C SYSTEM UPGRADE 16.50' (LENGTH) X 12.83' (WIDTH) = 211.7 SQ. FT. S 84° 44" 54"�N REPAIRED FOR: NEW 500 GALLON LEACHING CHAMBERi Q NEW VENT PIPE WITH 4'OF STONE PROPOSED EFFECTIVE LEACHING AREA: 7-ELEVEN CONVENIENCE STORE 4"PIPE INVERT= 95.2' LOCATED AT: MIN. 10'OFFSET FROM PL 70 93.20 LOT#1 SIDEWALL AREA + BOTTOM AREA PAU'L LAMBERT C - 10Y 7/3 117.3 SO. FT. + 211.7 SQ. FT. = 329.0 SO.' FT. (329.0 SQ. FT.) x (0.74) 243.5 GAL/DAY 1149 FALMOUTH ROAD (RT 28) 243.5 GALS./DAY > 200 GAL/DA,Y O.K. CENTERVILLE, MA. RESERVED FOR BOARD OF HEALTH SCALE: AS SHOWN DATE:03-01-05 0 30 60 120 FEET of Mqs PREPARED BY: oaf Ror3ERTA. cy� KCJ ENGINEERING DRAKE m ROBERT A. DRAKE PLAN OF LAND 144" ____l o CIVIL p No.41642 66 GREENVILLE DRIVE SCALE: 1" = 30' sioN:� FORESTDALE, MA. 02644 NO GROUNDWATER OBSERVED AT 87.00' Drawn By: Designed By: Checked By JOB No. j 1 I 1' I I f ..,. _ � . .,. Wk _ � .... ..._ sue._. _, Mg IF _ �- - _ IF We WIN _.,,. Company Name: Centerville Food Mart _ Product Category: Sushi & derivatives of Sushi (Uncooked, animal derived foods ) Location: 1149 Falmouth Road, Centerville MA 02632 Method of Storage and Ditrbution: Referigerated below 41°F Food Safety Concern: Frozen fish and cooken rice may contain pathogens Intended Use and Consumer: Ready to eat product, to be consumed by general public without further cooking _ Pr a Ste' -", , Hazard Identified Source Orrin probability oc ss _ o t p _ _ g p Y "Justification „ . =.Severit<,: . Risk Score PRP/OPRP/CCP,,, Control 3. r_ h _ - 'Physical Hazards Physical Hazards:Stones,plastic,glass or any other Poor hygiene practices,unapproved suppliers,us eof inferior quality raw objectionery material into food materials by the manufacturer 1 2 2 Safe food starts with reputable and reliable food suppliers who meet food hygiene and safety standards.These suppliers operate in a manner that Chemical Hazards - , " n an controls contamination of foods and ensures the foods are safe Supplier audit programs,On-site supplier audit by qualified auditors preve is d Purchasing&Receiving of Foods(All food for human consumption.Strict adherence to basic food safety regulations by of The XYZ,On-going process of performance evaluation of suppliers, commodities-D fresh and frozen foods) OPRP-1 Dry, Residues of pesticide chemicals in case of plant Unapproved suppliers,poor control over manufacturing practices the suppliers is a must to avoid the introduction of food poisoning establishment and maintenance of list of approved suppliers, 1 derived products 2 2 microorganisms to the food chain.Purchase dept.(Accounts-Cost control) Incoming inspection maintains a list of approved suppliers and the approval program is based on Microbiological Hazards the on audit by qualified auditors of the Organization Unsanitary practices by the supplier/manufacturer,failure of implementing food Introduction of pathogens into the food chain safety requirements by the supplier or manufacturer,failure to implement cold 2 2 4 chain Physical Hazards Introduction of objectionary foreign material into Poor hygiene practices,uncovered water tanks food 1 1 1 Chemical Hazards f Residue of cleaning chemical used forcleaning and Use of unapproved chemicals for cleanign&sanitation,deploying unapproved, " SOP for control of water supply in place,dedicated engineering team Receiving and storing of potable water sanitation of water tanks unskilled workers for water tank cleaningetc. Establishment,implementation,monitoring and verification of PRP for supply to carry out preventive maintenance of utilities,cleaning&sanitation PRP of water,water borne patlhogens are controlled by usning only approved water 1 program in place for water tanks, microbiological characteristcis are 1 1 for cleaning and cooking purposes verified annually. Microbiological Hazards - Multiplication of pathogens due to unsanitary Introduction of contaminants into the potable water line from the drianage, - conditions uncovered unprotected water tanks etc 1 2 2 Physical Hazards ' Physical Hazards:Stones,plastic,glass or any other Poor hygiene practices,unapproved suppliers,us eof inferior quality raw 7 1 objectionery material into food materials by the manufacturer 1 Chemical Hazards _. . Chemical contaminats if the supplier uses same If the supplier uses same vehicle of food and chemical substances,cleaning truck for food and non food materials;cleaning chemical residue used inside the truck g , chemical residues 1 1 1 "' SOP for selection,evaluation and re-evaluation of suppliers,on Further processing is done,likelihood of introduction into finished product is audit for suppliers,receving end inspection,Purchase in charge is Receiving and storing of dry Ingredients PRP less,supplier audit program,receving inspection program,maintenance of cold trained about basic food hygiene requirements,designated storage chain reduces the likelihood values of microbes areas,temperature belo 77 F elative humidity 60-65%;Humidity Microbiological Hazards &temperature are monitore at dry store,First in First out,First Pathogenic microorganism(of fungal origin)due to Mositure inside the delivery truck,Mositure is an extrinsic factor required for i Expiry First Out Stock rotation tc.in place. failure to maintain temperature-humidity, growth of bacteria/fungi,microbial contamination if delivered together/kept tampering of packing material etc. together with foods with heavy microbial load such as raw animal foods 1 2 2 Physical Hazards Physical Hazards:Stones,plastic,glass or any other Poor hygiene practices,unapproved suppliers,use of inferior quality raw objectionery material into food materials by the manufacturer 1 1 1 I Chemical Hazards Chemical contaminants if the supplier uses same If the supplier uses same vehicle of food and chemical substances,cleaning On site supplier audit,receving inspection,monitoring of core truck for food and non food materials;cleaning chemical residue used inside the truck;unapproved supplier temperature while receiving,etc.dedicated chilled storage facilities On site supplier audit,receiving inspection,maintenance of cold chain etc. Receiving and storing of Frozen Fish chemical residues;high levels of hormones/ OPRP-2 are available,_temperature shall be min.5°F while receiving folowed g maintenance of cold chain reduces the likelihhod values by immediate storing at-0.4°F;strict adherence to the shelf life as per antibiotics 1 1 1 manufacturer isntructions,First in First out/Firrt Expirt First Out etc are followed Microbiological Hazards 5 i _ 2, „ Introduction of pathogen E in fish sh Failure to maintain the cold chain b the suppliermm(Should be minimuus 15 etc.) degre Celsiu' hile receiving) 2 4 Physical hazards Introduction of hair,pin,galss,stone,plastic, Poor personnel hygiene,failure to implement cleaning and sanitation programs I — screw,paper or any other objectionary foreign etc. material into food 1 2 2 ' Chemical Hazards , Possible reisudes of cleaning chemicals if parallel Fail to implement SOP for personnel hygiene,cleaning and sanitation etc. Subsequent treatment may not be accountable to destroy all the pathogenic CCP 3 Thawing is carried out under controlled atmosphere,warmest portion Thawing/de-freezing cleaning activties were carried out over uncovered cells of Salmonella,Most common type of food poisoning reported in USA etc. of shall not be above 41°F,to be used within 04 hours food/if chopping board,knife,working table has 2 2 resideus of cleaning agent 1 Microbiological Hazards Multiplication of Pathogen(Such as Salmonella Inadequate thawing,prolonged exposure to temperature danger zone 3 6 spp•) 2 Physical Hazards ' Not reasonably likely to occur n/a 1 1 1 Chemical hazards CCP 1 Vegetative pathogens can survive if rice are not properly cooked Rice should be cooked to adequate temperature for destruction of Cooking of rice Not reasonably likely to occur n/a 1 1 1 ve et tivepathogens g a Mic`robioogical hazards'' I Survival of Pathogen Inadequate cooking 2 3 6 PhysicatHaza�rds Not reasonably likely to occur n/a 1 1 1 Chemical hazards Cooling of rice Not reasonably like) to occur n/a 1 1 1 OPRP 3 Bacillus cereus could grow and form toxins if rice is time/temperature abused Y Y Cooling is carried out in controlled conditions(less than 41°F) Mic obiogical hazards, Multiplication of bacteria Bacillus cereus could grow and form toxins if rice is time/temperature abused 2 2 4 Physical Hazards Not reasonably likely to occur n/a77 1 1 1 Chemical hazards CCP 2 Bacillus cereus could grow,and form toxins if rice are not properly acidified as Acidification of rice Not reasonably likely to occur n/a 1 1 1 bacteria can not grow in acidic environment. Maintain acidity of rice at 4.1 and it must not be exceed 4.6. Microbiogical hazards' Multiplication of bacteria Bacillus cereus could groow and form toxins if rice is not properly acidified 2." 3 6 Physical Hazards _ - — ---- —— Not reasonably likely to occur n/a 1 1 1 Chemical hazards" i Assemble nori,fish,avocado,carrot and rice Not reasonably likely to occur n/a 1 (Including cut into slices) 1 1 PRP not reasonably likely to occur due to short time Microbiological Hazards not reasonably likely to occur due to short time n/a 1 1 1=. Physical hazards �. .. Y Cooked high risk foods intended to be kept under refrigerated storage Physical Hazards:hair,nuts,screws, Stones, Poor hygiene practices,unapproved suppliers,us eof inferior quality raw Excessive time for coolinlg of high risk food is one of the key contributing prior to serving,are to be plastic,glass or any other objectionery material, materials by the manufacturer 1 factors to foodborne illn(esses.During extended cooling,foodborne pathogens cooled from 140°F to 68°F or less within two hours and then from 1 1 that may contaminate cooked food or developed from surviving spores and 66.2°F to 41°F or less within 4 hours(total 6 hours).Foods that are may grow to a sufficient number(and/or produce toxins)to cause illnesses. cooled this way and stored chilled should be used within 72 hours Chemical hazards By reducing the cooling ttime,the risk for pathogenic bacteria to grow to a from the time of preparation.Rapid cooling;of foods by: cleaning chemical residues;if cleaning activities Inadequate cleaning/sanitation/hygiene activities etc., dangerous level(and/oir producing toxin)will be minimised.Food stays at the .reduce the volume of the food by dividing it into smaller portions Cold hold/cold serve were carried out parall danger zone for more than 2 hours during cooling.Rapid cooling prevents and/or placing it in shallow ely over uncovered food; 1 CCP-4 1 1 multiplication of bacteria.If the cooking step prior to cooling is adequate and i containers; no recontamination occurs,all but the spore-forming organisms such as cut large joints of meat and poultry into smaller chunks before Microbiological hazards Clostridium Perfringens should be killed or inactivated.However,under poorly ' cooking;and II maybe z Salmonella Multiplication of bacteria/spore forming bateria Slow cooling,prolonged exposure at temperature dangerone monitored conditions,other pathogens such as S •When cooling equipment is used,ensure there is space around the such as Clostridium spp. reintroduced.Thus,cooing requirements have been i food containers so that the cold 2 2 4 based on growth characteristics of organisms that grow rapidly under air in the refrigerator or cool room can circulate freely. temperature abuse conditions. x + I Tel 1•/tN�� �. .�-«..�.�--�t i i � _ + ►• ._.~ _. } 1 `} Z2� -to(cI E, ir`n P �2S ! 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O 3 l O o , : Q I ° 5 4 � - ;s 4 5 C' � / 4. ,. O 4 O / BUSINESS DISTRICT `URBAN B IN G RI , SHE LL 1 ZONING DI 8 L `C 9 N 5 Cn �/ o _ o . 3 L G Y BUILDING 3.3 /o c COVERAGE UI DIN o LOT CO ERA B B P a_ f I _ 2 , / 0 i �N E \q R 8 Q I- P N 4 4 0 R E P _ a c� TRAFFIC C T Q L E l 0 29 5 NUMBER 2 o 3 ASSESSORS N M N S R P a AN D 7. T R � L1G H 3 6 2 � I N 4 3 N E N E R G 4 3 - :`D . G a 't, � Z ZONE C_ 5 P N G u 4 FLOOD HAZARD � F v M 0 0 : T v G J G P N O q : , P , 2 < SEPTIC , G SE I L UNCOVER VE EXISTING P� _T SHALL N 0 R s s 5 . CONTRACTOR H . R r S ( STONE E 0 N E Q � V s' _ P 0 L ' G A m R i SHAD.. , \ ,o EGISTERED ENGINEER 4 E TANK AND A R � I 4 g f 9 F 3 4 cP E 9 F N 3 � 5 T T T THE SEPTIC TANK T SURE HA H PAR INSPECT 0 IN 0 \ PAR KING G -m Q 4 O S : O cs a 1 6 G k 9 4 5 3 5 - V VEHICLE LOADS .` T SUPPORT EHI E SUITABLE 0 S PPOR 4 E IS SU AB E � 8 I E N 4 4. N G R P 0 SYSTEM. . 6 . ALL PRO POSED SED SEWAGE _DISPOSAL G 0 � AR EA A l `� 'I ca O 9 2 P / 1 4 w P Q LOADING V 20 a COMPONENTS TS SHALL HA E H M LEA , OMPON LEACHING O � v S ING _t 0 z P O s ? 81\ 9 a 3 N 4. N S 0 4 , � \ 3 T � Y RENC \ 9 'H 3 CAPABILITIES � CA ABILI I 3 3 P E ;4 Q 4 N 0 , N "� 5 � _ 4. R a O � G N 4 a 2.5 -.HYDRANT D P/ EE , O 8 a x L � 7. B N A K _ P F BONNET NUT E CHM R202 TO 0 0 NET T s 5 L0 5 5 w � r l H Q G .� EL E V 46 65 \, 7 _ s I. 8 ACRES 7 0 a 3 3 E 6 J R 6 Z a 5 5 4 3 1. 6 -Q \ / F tt _35 4 2 O P s , N / 6 � 3 P �- N � 0. 5 3 _ 4 E 8 � l N 7 O � v � 3 P i 6 \ u CA s 0 ,P E / P 2- € x R M I! v . R : LEGEND G , O 9 0� P 0 P N � k 5 \ cr L N R E P _ S P ` ; \ R F. P N .8 9 , 6 A L N 4 , 0 4 N w/ L v 5 2 2 S 3 P - \ 2 ? 6 . E , R 4 N 1 \ _ -SPOT ELEVATION 3 a b i 1 . 00_. OQ _EXISTING F / 4 i G ; 3 V ELEVATION 2 0 0 PROPO SED SPOTE E A K 0 . 0 5 C—� � 5 _ _t O 4 Y 0 ,.D2 / t 5 V / 5 4 z S _ 2 B PROPOSED PAVEMENT\. 3 � a . c / , 5 � F _ 4 R o, ,, o + o . . m 0 AN N s / _ E E .. R E t�G . N P Co0 B r C .5 . T _ 6 N N 3 . l� \ P HE TO 2 5 S ry E — 1 R A 2 / o X ? S 0 4 _ ,. c 9 \ G _ . T\ V r E 5 � . M �J, E ,4 P -_ 1 R 0 .5 E� 6 B 4 E E N S S .. O G a O P CSC M , L P L _O P ' a R R _ E P � B ,. R E _ a O O S 6 E a 8 _H R 6 N P G P 4 S R TE / M C BE RM R R N G _ / D N SE , TI , XI S 0 P 0 W PR G tv E E P H . E S E A - s P N A B A 8 F, / S L G 0 6 i I S B J G,8 N � , 4 T� S XI P 4 6 -i - 8 E D_ T 3 Q 0 3 � I _ AN 0 I I A 3 O , 5 J , _ M1 P T 0 B 4 P I T . ._ G N ., A C H �. 6 N L E '. 6 _ TI 3 Xl _: 6 5 'S 9 S E 4 _ 5. _ 3 4 2 3 I NE D � 0 t 0 1 da ,. A AN D E T 0 BE 4 S 6 D 4 E _ Fi L. 0 P AN D A .8 R -o E R T D , S E 6 M P ST AKED U Q � :, S _ D D PR OP 0 P S E _ E L O A Y B o N H E N C E 1 o - c� 0 -�- Y 9 O 4 _ E N 5 R E A , � 6 4 N >.� G . O 0 3 _ 2 c 8 0 o ? 5 _ 4 � ` 3 v P : 6 6 5 I E a. C g O O g 5 / E P N 6 G , `i 4 D z- \\11 V ,O M $ _ - E 5 E R E Q 3 O \ i P O 1 v g _ G R E g 10 F -._ TEST H OL cp. 3 - O E D � v � 0 � ,5 6\ R M 4 6 O i 4 I J 0 , I ? 6 4 5 4 \ 8 4 3 4 5 F —� O 'O . 1 —� G 4 5 T s 0 Q� c 4 G ,4 F .5 4 2 P 6 O �v 4 �_ Q� O O _ 9 4 Q 2 5 � P TO BE 41 A :'L I0 STRIP J 4 c O I _ O LANDSCAPED O A O 4 _ LOAM 4 c , - 4 O ; •9 SEED 2 9 ' 2 6 S A s 5 9 2 7 \ 4 ? \ I 4 6 4 •9 P `9 UTILITY 'POLE I PROPOSED H SHRUBS, A FO RME R �9 WITH R NS O 2 ,I �9 4 O __ 6 5 AD D OFFSET T RT. 28 :ADDSIGN, 4 , 0 S 0 ? ? G O 4 A F K ` H A A DD L1MIT W R AND YB LE MJB 0 � G 110-26-841 0 0 S e a N 6 DATE DE S E C IPTI N r n S R 0 Dow B Ch k ed , o o � � y c .. 5 _ �9 9 A , UNIT- O A/C �C. 3G EV R I I N5 8 SO � �, AB N C N c. sL N `I 1 0 0 7 1 4 4 8 8 S Ik O ro 0 .UN'D�ERGROUND TEL . 9 SITE PLAN OF LAND I MARK R i N E I O n F PREPARED FOR �P -o 0 .3 \ - 48 � THE SOUTHLAND CORP . : 0 3 C <' AL , SIGN IN SIGN A ST E B RN ABI� 4 HYANNIS MASS . LO T 6 _ ... 15 .._._ . JDATE: OCT 984SCALE. , 1 2 0745 � ti r holme and me rath inc . r r civilengineers and land- surveyors A. 1 t R A. N 1 G , 2 main street A N 00 n r 1 iVi�.39255 2 Q _ 54 fr a ut a . 02 0 f lmo h m w i � � f c t fi w ¢' Ei S f f. 0 dA , C C W J CHECKED DRAW N: M B A-f3 4 DWG 0 29-4-2 �2 ; JOB N0. 8 413 D N H T I S EE 0F 2 I , „a i 1 ' ,r f , 7 rn' -an I _ r S 0_ , -�-—_CONCRETE_ r F n h 9 r ode abov ea nd a ocent to system m shall slope e amln.0 f 2 /' away from, r omsystem .� dAT E' FS SOIL TEST.,_SEP 20BLCCK BAIOF DESIGN ;I 4 , t T BURGMANN WALL N BY F� BER ,TEST TAKE 0 1 1 ES dam .cast iron r-Schedule P n t o o S due PVC a In tall with tight nts ,' 4 0 s )P � , 9 Y. . AC p W 8 J. J WITNESSED f31 R 0 E T5 >. m rnm m- $l1 L 20 u distance b +1 . .,d+ a f I 1(building to a hn system oc s e -; g s C9 Y FLOW FROM EXISTING RV A 4 g 0 0 I SERVICE E I P T S C ST T N 3 EMPLOYEES` A 5 G PD S 0 L E T 15 P 0 S G D RAT M N �R TI 2 C ON E 1 T _ PE IOLA ft E CO N E C ml 1 t 0 s . A ,. L . ARE _2 FLOOR F P 0 ROPOSED 7 E. LEVEN 256 A 0 F.S T 5, G A /I v�A K, L. 00 F. 12 E L S. S Cu PD. N 1(lf4TE TENCOUNTERED S t p GROU p fi 0 N TO P P OFh ?, -I mrn PITCH 1�'3 Fou�pATl v 3LEAC INGCAPACITY REQUI ED - .- T n ♦. PITCH CN 88 - 84IDE min. w AREA FT80 TOM AREA S Q. FT - 6 r _ . ...��: � rn C NC E E FLOOR 0 R _ SQUARE I L LOG5. AREATOTAL EXI ING FEET .. _ . 548 G:P D. ; EX.(STING CIT GC6 EXISTINGLE LEACHING G CAPACITY CONCRETE GASOLINE STATIO N N N o N o SUPPLY: TOWN t FOUNDATION ? WATER Depth Soils E Depth Soils 2 + 8 PRECAST REINFORCED CONCRETE UNITS S 0 47 6 r F H LOADING . LO AM, AM , R 0 2 0 _ a , -Removable c ver Covers.. UBS IL ; - S 0 _ _ 10f� _ . .... . .,. . Removable j� C_ A SECTION ,. TY PICAL PC I L _ _ s 2_ Cove, .0 ve 2 c Removable Re ob s 4; 6 0 .2 #1 i i , Clean t. . r back cover , SCALE ), e T S L N T 0 )0 , o I , a, NOTES 1 , , N O S ` r r : - a 2 Dyer aS# ' , MSAND,EXI TINGO0 oo ton e SOME oaMADE UNLESS —SEPTIC TANK — . BOX CHANGE T© THIS SYSTEM M SHALL BE To 'GRAVEL L OO O040 GAL _. _ , .. a 1 1 .a 41.6 f 1 6 6E f the' r eG e.. CGR H INC. , 1 ,1 H LM S AND M AT 1 Y 0 { WRITING B o APP VED N R RO � , ,;F r .` > Dep th Qv P ,. 0- MEDIUM M E DU p0 A HALL BE KEPT ' ON SITE .. O. O'. t P F THESE PLANS S S 2 A Y O T S .H 0_CO S w 2 0 . aaC > i 3 SA ND p W Precast to v . C ,C C C o” o. !3 3 ' A P DURING L cHl T RNG ' e E N UG o O c. ter. o A H A -8 FURNISHED T A LAN SHALL E S 0 COPY F THESE PLANS S 3. 0 T S 0 .. 2ft 2 ftC0NTRACTOR INSTALLING THE SEWAGE DISPOSAL SYSTEM 6ft.diam, 4 # f tl 'to 2t 4 w e �' t washed stop SHALL T TRAVEL (/2 as L NO C EQUIPMENT: S TR TONt d C Uat reca t , ,4 H AVY ONSarour+ s t roved n an _E _rR, P P F E 9 PR 0 tL effe f lo ft.ftAFTER CONSTRUCTION.DISPOSAL SYSTEM DURING 0R N iot to s cat' . e , PROPOSED SED7-ELEVEN 5 SEWAGE DISPOSAL SYSTEM SHALL BE C NSTRU CTED IN FIRST FLOOR ELEv._ 6.88 _ ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRON- MENTAL CODE. ; t 6. HE Y TE HECONTRACTOR ,AKF LI G T SS M T F` 8 C I Nc'BEFORE OR L s- 0. 2 _ NO TE : INVERTS IN ER F H O THE NEW _ C M S 0 P NE f tD 0 NTS 0 TH , A RD - 2 _ E R TH E BOARD 4 D BATHINC. ANOTIFYH LME AN MCG N< ,SHALL0 S Q S t b SYSTEM WILL BE ESTABLISHED AT THE TIME r. HEALTH AGENT T0 INSPECT THE SYSTEM AS CONSTRUCTED. 000NSTRUCTION WH WHEN ' THE EX ISTING SE PTIC PROPOSED _ . TANKUNCOVEREDINVERTS , I STHA' SO T IT XI TING S s E S a , AP EA E TR 'CAN ' BE ` D GR S DETERMINED. TANK SEPTIC T _ 2 t S E P i GAL. L ,1 ., 1000 ., 1 t A, r 00GL. 10 o> . ... ,W W x- LL t FoundationDesigned ,r 'F a 0 OU , 5 a ir<- c K L t v .. r Others 0 t s r PROFILE r r No to sae r r , � Z r O_ t , + t I>outlet from r fi n All I f d s1 x I e s o h8 bu o t �. ou bo sha Outlet t1: ! f f` f . _. a o f least f#,f m t, beset eve. 2 r o he box r � l Kn tt o � u t -9 0 oc o s , D , 1 t ! . 4 1 T -�.- UT INLET T OUTLET ,E ,.. _ 1 1 - l � r fo t c Ta Manhole covers s S e All tlhbe o_ A access M P v r_ ( s t _ �A _ r C r x and/ or Leaching Pits se --�---- _Bo L . . .Distribution b . . t,. is , r g r M r h 12 shall more than b lovr finished rode sh be: e 1 _ N ET _T 9 L OUTLET a if _ hl Igrade. Outlet , d t wet n 2 f finished ed.rase. o o i h ..... �. rt k tt . ,K oc ou s cove concr ete '.'tal frame cover or on e I e � „ i M t tl h r required.over "T s where e e u ed. ; o i 4 t tt . _ ,t 2 _ A DET AIL 0 t , IC L TYP , E D CRIPTI r n ES N D 0 aw b Che coed b Y' _ Y f r <'SCALE) Conc rete block masonry (N OT T TO S 1 _ -. F T r a .. IEIN C D 'PRECA T CONCRETE o ,STEEL R OR E PR ECAST _ -,. 1 a r . r � a R. Court .cv E' V cee oe iON t ver_ $ S C o Brick m -- , . . _ Y 8 k masonry C tl o t� . . , .� 3 A I T , 3 bl covers Removable 1 AN � Q SHEET . L _ t r . . , . INLET � _ Outlet 0 ,Ou t et e ,_ _ r 4 d l 1- UTLET required—" k m n:cis ranee re Knockouts , .u t , Knock q �( a oUtS » , E NL , 1 y PROPOSED A D. R A 'E M_ � 0 OSED SEWAGE, I SY T. S E D P L S N 13 , S OS LET _ $ J 1 1! f mi n. ..2 min.ln et to Dote 6 U T r E T ISM. R -PA FOI I P E RED Li u d lave�10mrn. 4 _1 11. T min. — HE S OU TH A .. A a L ND CORP ' ', r , E 4N a+ O 1= a+ , O v O II DISTRIBUTION T C�11. X YPBO 1 _ , d- _ 1 t I1 H YA N MA _ CAL . ._ Q S E 0 h" ate l s w D 984 e son _ . OCT CT.__I 0 5 J , fi i and mc oh c _o rn es r 2 , r �i engineers and land surveyors civil era s _ .e n es Y _ f A. .. 5 r /Y r _ __ _ r? t G R _ P�: 9 5 � ._ 0 3 2 m m t 00 street , . . r. r #a m ut a.( o h m 2 4 0 5 0 r T T TI TANK _ P A GALLON SE C �,. Y l CAL . 1000 G LL ,P ., t k 1 r � -Checked t t ra w n Ch c 8 Y, _ l� ,C3 a _/8 _Y _ . , SCALE. I S L 4 5.. ..: ,:. 7.. e..., .. B .N ET 2 F .r. JO N 8 DWG 0 2 412 4 2 9 vl 4 2 _ . , , , , : I