Loading...
HomeMy WebLinkAboutCASUAL GOURMET - FOOD (2) TCASUA (5t RMET 31 Richardson Rd. Centerville Mp bq5 :1 Town of Barnstable BOARD OF HEALTH � John T. Norman Board of Health Donald A.Gaudagnoli,M.D. BAnSISTAUM. F.P.(Thomas)Lee,. MASS �` Daniel Luczkow,M.D. Alt. 200 Main Street, Hyannis, MA 02601 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: 67 Issue Date: 01/01/2022 DBA: CASUAL GOURMET OWNER: THE CASUAL GOURMET, INC. Location of Establishment: 31 RICHARDSON ROAD CENTERVILLE„ MA 02632 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 24 OutdoorSeating: 0 Total Seating: 24 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE- ICE CREAM: C�i FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Akk 09-"�k �W' .� Town of Barnstable Only.For Office Usse Initials: Date Paid I Amt Pd � u�vsras�. ; Inspectional Services Mass ( tb39. �0 Check# ��� � a Public Health Division fp MA'1 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE ►1 2a21 NEW OWNERSHIP RENEWAL )( NAME OF FOOD ESTABLISHMENT: C4 Su cU C3 oQ rrne-t, S.r c- ADDRESS OF FOOD ESTABLISHMENT: 31 R.i e"c Lr-dSo n 9—ck, Cer�tee 1 Ne AMA 021o32 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Same. cis above E-MAIL ADDRESS:___M0.t-v�@ tlne c�sve.lcao u c met,c om TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (5ps )115 - 4�14tn TOTAL NUMBER OF BATHROOMS: 2- WELL WATER:YES NO X ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_� SEASONAL: DATES OF OPERATION:_/_/ TO NUMBER OF SEATS: INSIDE: 1$ OUTSIDE: O TOTAL: 18 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? N O IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? F-S TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) X 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 Forms\FOODAPP REV3-2019.doc OWNER INFORMATION'c FULL NAME OF APPLICANT - CGLSOctA SOLE OWNER: YES./NO ; OWNER PHONE ADDRESS CORPORATE OWNER: C:0,1st;a t C-tovcm. CORPORATE ADDRESS:. 31 R tcl�acr�5orn Rd, C h�ec-v;1t } MA 02to?;-,� PERSON IN CHARGE OF DAILY OPERATIONS: Sae S�t4-1 tcZ List(2)Certinted Food Protection Managers.AND at`least(1)Allergen Awareness Certified Staff All FOOD ESTABLISIVYIENTS must have 1 Certified Food Protection Manager PER SHIFT'., **ATTACH COPIES OF CERTIFICATES** The Health Div. wiII.NO.T usez past years' records. You must provide.new copies and POST THE CERTIFICATES at your food establishment. Certified.Food Managers Expiration Date Allergen Awareness. Expiration Hate Z02 0 MA rC21 Dui v 15 \O / :29 !2022 1�tsl� C,06 o 2: ro SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments, ts,including mobile truck§.must be inspected by the Health Div. prior to of eniae V! Please call Health Div.at 5.ob-8624644,to schedule your inspection: Please.call at least(7)hays. n.advance: FROZEN.DAIRY,DESSERTS: Frozen desserts must be:tested by.a State Certified lab prior to opening a n 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 Bamstable must notify theTdam by fax or.mail prior to'catering event. You must complete a catering notice found at bttp://tvww.town.afbarnstable us/health&isitaro/a licatiptt dg ;. OUTDOOR COOKING: outdoor cooking,preparation,or display of any food product by a food establishmeni is prohibited. NOTICE: Permits run annually from January I st to Dec..3:l 6`each calendar year. IT IS YOUR BES.PONSIBILITY TO RETU1tN` THE COMPLETEDAPPL.ICAT.ION(S)AND REQUIRED FEES`BY DEC 1.st. Q:Wpplioatioa FQrms\FOODAPP REV3-2019.doe =� Z S, pVE Tp TOWN OF BARNSTABLE _ HEALTH INSPECTOR'S Establishment Name: Date: Page: of _ ep kti OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. �!. _ MON.-FRI. 'cbp ,639•sum HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY TEOMPr FOOD ESTABLISHMENT INSPECTION REPORT ?> �_. Cr Namea�n Dat f Ins ction2 Routi Address 3 ( �-- Risk Food Seroi Re-inspection Level etail Previous Inspection Telephone Residential Kitchen Date: 3 }� Mobile Pre-operation I Owner /1 s: HACCP Y/N Temporary Suspect Illness / 63, G� 0 I�`� Caterer General Complaint Person in Charge(PIC) I'S IVe Time Bed&Breakfast HACCP In: Other Inspector ��.p Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) �J - - A Tr, I ?' Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ K Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands '� VYA AU �/� ❑ 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 b ❑ 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 �/1 PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control �'( 2 e6- -L'I ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ' ad'/ (/U 1 ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY r ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories - Y�- Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations ' a- vh L, 't 10- 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 r g 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ g y ❑ ry P 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 d lessh 9 non-critical. If critical water, a back-up, 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must and than non-cr no cr er,sewage p,infestation of rodents or insects,or lack of 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 within 10 da s of receipt of this order. violation,4 to 8non-critical v lations=C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: Inspector's Signat a Print: U - 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 Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) ' Assignment of Responsibility* 8 Cross-contamination .14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12-;- Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 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 7-201.11 Separation-Storage** 3-501.16(A) Roasts Held At or Above 130°F* - Applicants* - 3-302.11(A) Food Protection* P g 20 _ Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An _ 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use*- 3-501.19 Time as a Public Health Control* 590.003(G) Reporting by Person in Charge* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 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 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 Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 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* E11-r;ve;nrzoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22:0* Contact Surfaces of Equipment* - 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* -4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I 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 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 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* 3-40 1.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 - Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercially Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* Lis Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification* ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 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 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 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* I 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. ., ypFTHE rp TOWN OF BARNSTABLE .HEALTH INSPECTOR'S Establishment Name: - Date: Page:. of ' _ ti OFFICE HOURS BAR E.O` PUBLIC 0 MAN STREET 3 30 4 30 P.M.SION - '800-9:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MA SS. g. MON.-FRI. 9$, 039.boo HYANNIS, MA 02601 508-862-4644 No Reference R-Red Item: PLEASE PRINT CLEARLY 'FON1P� FOOD ESTABLISHMENT INSPECTION REPORT fI Name Date P 2/ Tvne of T Ins ection outine Address Risk Oood Serv' s Re-inspe ion 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) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red 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 Emergency Closure checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ 9 Y ❑ 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 4 non-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. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if:-no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of ( )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 7 30.Other DATE OF RE-INSPECTION: Inspec s Si atur Pri 31.Dumpste�a eened 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 f 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$ 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 7-101.11 Identifying Information-Original Containers* Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge[0 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person.in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated 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 Warewashin Hot Water 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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* 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* 3-401.1 IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef°&° uuZoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( )-(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. * 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 [-I,- practices should be debited under#29-Special 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11 A&D PHFs 165°F 15 sec* $ Receiving/Condition ( ) ( ) 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 non-critical 23-30) 3-202.15 Package Integrity Y Critical and non-critical violations,which do not relate to the foodbome * 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated 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) Cooling Cooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification* g Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F[0 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 Supplied with Soap and hand Drying Devices Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' - 27. Physical Facility FC- 7 -7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. pF IKE rpw TOWN OF BARNSTABLE _ HEATH INSPECTOR,s Establishment Name: J k ( 4 4 Date: SIT71 19 Page: of ti OFFICE HOURS P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. - 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified v .659. HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY 508-862-4644 p'FDN1P`' FOOD ESTABLISHMENT INSPECTION REPORT Name Date T of T e f Inspection , � �� ������ ions outin Address ` G�G���C (� I Risk oo ervice Re-Inspection Level Reta- Previous Inspection Telephone Residential Kitchen Date: Mula Lofc Mobile Pre-operation t Owner HACCP Y/N Temporary Suspect Illness MAkh I'll s I Caterer General Complaint Y' , Person in Charge(PIC) Time Bed&Breakfast HACCP - v✓01 I k in LnQa/. Lle In: Other Inspector Q (A Out: `�" J �b sJ - ( - .� r1Z✓ 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) ❑ �,(- �>`7 ✓ 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 ,gyp EMPLOYEE HEALTH PROTECTION FROM CHEMICALS t ®f V ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives �� 6G siobo 4,t: y ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals _ pi / FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Vt/ ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures J ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling �" Lt r ©�� V ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding F' 1 PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control �-S '✓Vhk4 ✓ ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) K9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 4 �_� _,/ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ® Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ® Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ® Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than 4 non-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 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if:, no hot C=2 critical violations and less than non-critical. . f 1 critical refrigeration. critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to anon-cri 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address non-critical violations. If within 10 days of receipt of this order. violation,4 to 8 non critical violations=C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view S". 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 / Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(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* 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Se azation-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 Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) q 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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 Wazewashing-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. 1g 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* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Staffing 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 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 es should violations relating to#good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. $ Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items non-critical 23-30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbore * 12 Prevention of Contaminat on 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 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from',Employees* L18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * ( )13 Handwashing Facilities 3-202.18 Shellstock Identification ; 3-501.14 A CoolingCooked 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 5-20411 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 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 Specialized Processing Methods* 130. 1 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. Ft . TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: � � �,��j��Date: n i age: of OFFICE HOURS T PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS, MA 026 1 M-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY 508-862 4644 'FON1P� FOOD ESTABLISHM TINS C ION REPORT Name YI Dat a of Ins ection a Rou' Address is JFood Service- a-inspe "on r Previo I sego Level ,�,���`UU Telephone An I Residential Kitchen Date: l Mobile Pre-0 i 1 Owner HACCP YIN Temporary Suspect Iness Caterer General Complaint / _ Person in Charge(PIC) Time Bed&Breakfast HACCP Other Inspector VV t. Each violation checked requires an explanation on the narra tive p e(s and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Ris Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ a Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ 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) A IV ❑ 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 Itemsl Total Number of Critical ViolatioI AVO)re Critical(C)violations marked must be corrected immediately. (blue&red items) A 19 Corrective Action Requir d. ❑ No 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 ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the i m ❑ 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 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 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critic I viol tions. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. vjpLatLpn,4 to 8 non-critical violat' s= 30.Other DATE OF RE-INSPECTION: Ins is ignatu int: 31.Dumps ter 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 Pit C'sj-S gna re 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 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* *_ 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 590.004(F) - Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.1](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°F * 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Se 3-501.16(A) Roasts Held At or Above 130°F* 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* q 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 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 Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13. Shell Eggs* _ - - Sanitization Temperatures* TIME(rEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.I IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of - . Clean Utensils and Food Contact Surfaces o * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* 460111A( ) Ut t f f Eggs-Immediate Service 145°F i5 sec Equipment* Not Otherwise Processed to Eliminate 590.606(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef erive 11U2001 4-602.11 .Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and 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- * - Ratites-165°F 15 sec* in mobile food,temporary and residential Sources 10 Proper,Adequate Handwashing g' P Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )( ) 3-201.17 Game Animals* 11 Good,Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,.Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the 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 3-202.18 Shellstock Identification* 3-501.14 13 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 5-204.11 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 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. oFt„E* TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: � Page: _of., c`` OFFICE HOURS PUBLIC HEALTH BARNSTABLE. 2 0 MAIN STREET DIVISION :3- - - . 3 0- :30 A.M. 4 33 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 0- P.M. HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY p +639•n 0 508-862-4644 - 'FO FOOD ESTABLISHMENT INSPECTION REPORT Name Date T e o s c ion O e Routine Address Ris ood Service on Level Reta1 Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Y,6, Caterer General Complaint - Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other s (/� Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red 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 Hand a ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities _ EMPLOYEE HEALTH PROTECTION FROM CHEMICALS I ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives Arl ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals r.s FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardoods ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures in n - I V ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling r. ❑ 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) G ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSI� ❑ �{� Cal/ 10.Proper Adequate Handwashing CONSUMER ADVISORY lv�_❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations jq, Critical,(C)violations marked must be corrected immediately. (blue&red items) I 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 B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 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,c to anon-critical violations. If 1 critical refrigeration. ( )( ) violation,4 to Snon-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpst Greened 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 ture Print- Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N SCAM Dumpster Screen? Y N "-��� E 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 ti 3 501.14(C) PHFs Received at Temperatures.Accordmg to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14„ Food or Color,Addihves a d 1 t ' t C 'Law Cooled to 41°F/45°F Within 4 Hours* _�. -..- _r ... , ., ,.,. { 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from I :":3-202.12 "ta_' Additives* 3,€t 3 501.15 Cooling Methods for PHFs a Cooked and RTE Foods.* ! '' - * ..19_ - PHF Hot and Cold Holding 2-103.14 - Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives ` Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below.41'.F/45°F 590.004(F) :. ! EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each I 7-101 11• Identifying,Information-Original Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* ' 2 590.003(C) Responsibility of the Person-in-Charge to - - - 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 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 Reprt 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* Contaminatloo 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 Reservice of Food*. 7,204.12 . Chemicals for Washing Produce,Criteria*. , HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g. ) Disposition ofAdulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* F213-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* Y 7-205.11 Incidental Food Contact,:Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-200.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A7B) 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 HermeticallySealed Container* Sanitization Temperatures* Unopened Sprouts Not Served*'` r,- * P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I.Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell_EggO _ 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 i 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 Eggs-Immediate Service 145 Utensils and Food Contact Surfaces of E °F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* w - Egpment* ' °' - -- -- - '` Not Otherivise:Processed to Eliminate .;,. 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001 4-602.11_ Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702:11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 3-201.15 _ Molluscan Shellfish from NSSP Listed _ _ Chemical* g g 590.009(A)-(D) Violations of Section590.009(A),-(D}in cater- RatitesSources* sec* ing,mobile food,temporary and residential 165°F 15 s 10 Proper,Adequate Handwashing a' 3=401:11(C)(3)' Whole muscle;IntacrBeef Steaks 145°F*'" ''° kitchen operations should be debited under Game and-Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Ames* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to * 2-301.12 Cleaning Procedure* 165°F* ,,as'r ,a,sr_.a+, , foodborne illness interventions and risk factors. 3-202:18 Shellstock Identification Present ;, I * 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* i * 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 PTO GOOD RETAIL-PRACTICES 3-301.12 Preventin Contamination When Tasting* * (BideTtems 23-30) 3-202.15 Package Integrity* g g 3 403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violatrons;:whrch-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* O g- illness interventions and risk factors listed above,can be found in.the- 590.004 E Preventing Contamination from Employees* - 6 Tags/Records:Shellstock O g18. .- 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 Item Good Retail Practices FC 590:000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible dd Within 2 Hours and From 70 F to 41 F/45 F , Tags/Records:Fish Products 5-203.11 Numbers and Capacities* _ Wittim 4 Hours* 23. Management and Personnel FC-2 003 5-204.11 Location and Placement* 3-501 14(B)_- Coohng PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* 5-205.11 Accessibili Operation and Maintenance - Tem erature Irigr /45*F ✓ 25. Equipment and Utensils FC-4 005 edien[s to 41 F 3 402.12 Records,Creation and Retention* ty' p Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices. (J) 9 927. Physical Facility FC-6 .007-11 6-301.11 Handwashin Cleanser,Availability r • =r =1 - " '"t 7 Conformance with Approved Procedures/ g tY 28. Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision Ig ' 3 ( gie_y 29. Special Requirements .0.09 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 1 Reduced-Oxygen Packaging Criteria* _ 8-103.12 Conformance with Approved Procedures* e ci .=•:_f :^ _". 4 S 590Fonnback6-_2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. , v ----'Denotes critical item In the federal1999"Food Code or105 CMR` 590.000. Y- TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: �- of , OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-.9:30A.M. BARNSTARI.E. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS MON.-FRI. HYANNIS,MA 02601 No Reference. R-Red Item PLEASE PRINT CLEARLY. p .639•a e 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORTZ41917 -� Name Date Tvue of of l c ion ra Ions Routine Address IN Risk Food Service ection , _HA 4L • `vim Level Re Previous Inspection I 91 Telephone Re sidential ential Kitchen Dat e: Mobile Pre-operation Owner HACCP Y/N Temporary. Suspect Illness _ Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Zlzn 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 ` 011 ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous F ds) ❑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( SP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP hLAk ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY I ❑ 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 mustbe corrected immediately. (blue&red items) .' ': i 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 EmergencyClosure VoluntaryDisposalOther: checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ ❑ 0 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 B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t F is scored automatically if: lack of hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lac 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 anon-critical violations. If 1 critical refrigeration. e within 10 days of receipt of this order. violation,4 to 8von-critical violations=C. 29.Special Requirements (590.009)30.Other D CT Inspector's ector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N If N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's nae Print: Self Service Wait Service Provided Grease.Trap Size. Variance Letter Posted Y N ` Dumpster Screen? Y N \f Violations related to Foodborne Illness Violations Related to Foodborne Illness lnter enGons - Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) ;"w J '? FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to d ' _1, ., _ Law Cooled to 41°F/45°F Within 4 Hours* 1 590.003(A) Assignment of Responsibility* $ Cross contamination 1q ,., - Food-or Color.Additives,..,.... . : ._ „., .< 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 3-501.16(B) Cold PHFs Maintained At or Below 41"F/45°F 15 Poisonous or Toxic Substances * , EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-10111 Identifying Information-Original Containers* 590.004(F) - Other* 2 590.003(C) Responsibility of the Person-in-Charge to 3-501.16(A) Hot PHFs Maintained At or Above-140°F*7-102:11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F _ _ _ - 7-201.11 Separation-Storage* - - Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control -' 590.003(F) Responsibility ' Charge* 3-30 A Food Employee or 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 To The Person In Charge* 7.202.12, Conditions of Use 590.004 Requirements 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* (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)Returned Food and Reservice of Food* 7-204:12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS H$P 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition of Adulterated or Contaminated - - - - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7;205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*. 590.004A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) C liance P - 4-501.111• Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations "h,':? ` 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* - _. Sanitization Temperatures* TIMEITEMPERATURE'CONTROLS'"!: ` J' 'I ! 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1$ 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 5-101.11 Drinking Water from an Approved System* Eggs 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 - Equipment* t�° - --" Not 0[herwise:P[ocessed to Eliminate ;. . 590.006(A) Bottled Drinking Water* q P 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef cfi e 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 3-401.11(B)(1)(2) Pork and Beef Roast-130°F'I'll min * Shellfish and Fish From an Approved Source Eggs 4-702.11 Frequency of Sanitization of Utensils and Food -- * 3-201.14 Fish and Recreational] Caught Molluscan * 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec Y g 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 _ _ * g g 590.009(A)-(D) Yiolations,_;Section 590.009(A),-,(D):in 94ter- Chemical Ratites 165°F 15 sec* Sources* 10 Proper,Adequate Handwashin , - ing,mobile food,temporary and residential P q 9 - - - Game and Wild Mushrooms Approved By - - - * 3°401:11(C)(3)'` 'Wfiole'mus"cle;Intact Beef Steaks 145 F* � kitchen operations should be debited under 2-301.11 Clean Condition-Hands and Arms the appropriate sections above if related to ' Regulatory Authority 3-401.12 Raw Animal Foods Cooked m a Microwave 3-202.18 Shellstock Identification Present* ti 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 1 Reheating for Hot Holding practices should be debited under#29-Special "" Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* i _,__ --3 403.11(B) Microwave-165°F 2 Minute Standing Time* VIOL 4TIONS'RELATED'TO'GOOD RETAIL PRACTICES Pe P (BIue:Items23-30) :} >,•;, , 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* ( 3-403.11(C) Commercially Processed RTE Food-140°F* 12 Prevention of Contamination from Hands - * Critical and'non=critical.violations;-which do_not relate to:the,foodborne 3-101.11 Food Safe and Unadulterated* 3 403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the-- g Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees*, 1$. Proper Cooling of PHFs'' "' S`' following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3'S01 14 A Cool Cooked PHFs from 140 F to 70 F 3-202.18 Shellstock Identification ( ) g ConvenientlyLocated and Accessible Withm 2 Hours and From 70 F[0 41 F/45 F Item Good Retail Practices F 3-203.12 Shellstockldentification.Maintained*. 7 to G et C 590.00 0" 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){ Coolmg PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 •-- 3-402.11 Parasite Destruction* t Temperature Ingredients to 41 F/45 F 25. Equipment and Utensils FC-4 005 * 5-205.11 Accessibility,Operation and Maintenance t...r,+; ,�i Y * _. . .. ,, ; rr; 3-402.12 Records,Creation and Retention Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices" u (J) 9 g 27. Physical Facility FC-6 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 Provision ``'1 " t s 4 Drying Ul ?,F_?s _.•a,t __t,_-•,??- 29. Special Requirements .009_ ; 3-502.11 Specialized Processing Methods* P g 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* _ _ - :`i Y S 590Fomack6 2doc8-103.12 Conformance with Approved Procedures* i 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. i -.`Denotes critical.itero ri the'fedefal 1999'-Food Code or 105 CMR 596000. i Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARNSTAU F Paul J.Canniff,D.M.D. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 67 Issue Date: 01/01/2021 DBA: CASUAL GOURMET OWNER: THE CASUAL GOURMET, INC. Location of Establishment: 31 RICHARDSON ROAD CENTERVILLE„ MA 02632 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 24 OutdoorSeating: 0 Total Seating: 24 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: 1 ) MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �FTNE For Office Initials: Town of Barnstable Date Paid' Amt Pd$ � BMWSPABL6. : Inspectional Se To rvices check# � 1 Public Health Division AjFp��e 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: �L C�CI(Y► ADDRESS OF FOOD ESTABLISHMENT: -5I ldix(-c nw) t &+my]114 MO (04Q MAILING ADDRESS(IF DIFFERENT FROM ABOVE)):: E-MAIL ADDRESS: fnaa-u e4e 4 luj CaC�f eA. Carl TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (�23 ) Yl5-- TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO_X_ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: _ SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: OUTSIDE: 0 TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) ✓_FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED& BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) -CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc •fi OWNER INFORMATION: FULL NAME OF APPLICANTA C) 01 t "� SOLE OWNER: YES/NO OWNER PHONE# ADDRESS !j !Z'6IQ&A-W_n Q� ( _PJY► V 1 ��_ CORPORATE OWNER: CORPORATE ADDRESS: \C\C q/\q�{'1 1Lc� IJIdYI 1 tiP/IV�I I'P. !►1 CCP PERSON IN CHARGE OF DAILY OPERATIONS: Wye 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. �"o 2. �Ic or 1 © SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January I 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. Q:\Application FormsTOODAPP REV3-2019.doc L W BOARD OF HEALTH Town of Barnstable John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BAMSTAuM Paul J.Canniff,D.M.D. MAWL A. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 67 Issue Date: 12/10/2019 DBA: CASUAL GOURMET OWNER: THE CASUAL GOURMET, INC. Location of Establishment: 31 RICHARDSON ROAD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 24 OutdoorSeating: 0 Total Seating: 24 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Ca� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I For Office Use Only: Initials: °ft"E'°' Town of Barnstable Date Paia11T�:1 'ry Amt Pd$ 1AMSrABLB, Inspectional Services A.EOPMA Public Health Division Check# I Thomas McKean, Director 200 Main.Street,Hyannis,MA 02601 F Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE ���/ NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: <�,743v ADDRESS OF FOOD ESTABLISHMENT: f MAILING ADDRESS(IF DIFFERENT FROM ABOVE): l E-MAIL ADDRESS: r TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (,�9 TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/_ TO i NUMBER OF SEATS: INSIDE: OUTSIDE: d TOTAL: _1L_ 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? II IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? i TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED &BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE &NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 QAApplication FormsTOODAPP 2020.doc OWNER INFORMATION: _ FULL NAME OF APPLICANT SOLE OWNER: YES/NO OWNER PHONE# ADDRESS CORPORATE OWNER: CORPORATE ADDRESS: U PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 21 2. M tC/ SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. i i 8-862-4644 to schedule our inspection. Please call at least(7)days in advance. prior to opening.. Please call Health Div.at 50 Y P 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 III Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdiv sion/applications.asi). i OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q`.\Application FormsTOODAPP REV3-2019.doc f . IIEr Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. DMAMN �� _ John T.Norman 200 Main Street Hyannis MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 30513, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 67 Issue Date: 12/20/18 DBA: CASUAL GOURMET OWNER: CASUAL GOURMET, INC. Location of Establishment: 31 RICHARDSON ROAD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 24 OutdoorSeating: 0 Total Seating: 24 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: -• - -- - -- - MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: i PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: f • F114 r For Office Use Only: Initials: " Town of Barnstable • Date Paid Amt Pd$ MAW. Inspectional Services 4 � Check# z Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fag: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 1 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: � �( Clot) -' ADDRESS OF FOOD ESTABLISHMENT: 31 1 i&a R( Cale vi l le: HA--0L(D3Z MAILING ADDRESS(IF DIFFERENT FROM ABOVE): tpm� E-MAIL ADDRESS: VVfi ffie r1asod Qooirwvi.ems► TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (SDR) 7M- q9% TOTAL NUMBER OF BATHROOMS: Z. WELL WATER:YES NOX ... (ANNUAL WATER ANALYSIS REQUIRED), ANNUAL: SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: zy OUTSIDE: TOTAL: Zq 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)?-)�A TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL, MOBILE &NEW FOOD ONLY*** REOUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FormsTOODAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT�� SOLE OWNER(YES/ O OWNER PHONE# ADDRESS 7 C�r+�I ��PI�(���r�Y]f�_ . ��"r^,�� ��1���, C)L(13LIE CORPORATE OWNER: OfiyP CAnase_ FEDERAL ID NO. : C 4— �11 I-1 Iq CORPORATE ADDRESS: 31 1')il�°l�Ye�S�f� �� � 1��11I'�,t'i�e�(C IA 07—L1 Z PERSON IN CHARGE OF DAILY OPERATIONS: (Xi,'e. Cf1 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 Manners Expiration Date Aller en Awareness Expiration Date I. Ti i�� I�arr (T ���PP�c y l l�O c�o 8 / ZS / 'ZOZO 2. C I / ito /Z019 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 508-8624644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. e 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN NOTICE: Permits run annually from January 1 st to Dec.3 ac y THE COMPLETED APPLiCATION(S)AND REQUIRED FEES BY DEC 1 st. Q:1Application FormsTOODAPPREV2018.doc Bellaire, Dianna From: McKenzie, Marybeth Sent: Friday, December 21, 2018 1:20 PM To: Bellaire, Dianna Subject: RE: Casual Gourmet 31 Richardson An inspection was done on 7/18/17 with a grade of A.They were all set. From: Bellaire, Dianna Sent: Friday, December 21, 2018 12:35 PM To: McKenzie, Marybeth Cc: Bellaire, Dianna Subject: Casual Gourmet 31 Richardson Hi Marybeth; Are they okay for a permit in 2019? 1 have all their paperwork, however the last inspection we had was a complaint inspection in 10/2018. Let me know, thanks. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us 1 ._Bellaire, Dianna From: Bellaire, Dianna Sent: Monday, November 26, 2018 3:38 PM To: Kelly Field Cc: Bellaire, Dianna; McKenzie, Marybeth Subject: RE: FW: Food Permit Renewal 2019/31 Richardson Rd/Casual Gourmet Hi; I will place this email in the file. Please send the new certificate to verify when you get it. Thank you for the quick response. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us From: Kelly Field [mailto:kelly(cbthecasualgourmet.com] Sent: Monday, November 26, 2018 3:36 PM To: Bellaire, Dianna Cc: McKenzie, Marybeth Subject: Re: FW: Food Permit Renewal 2019/31 Richardson Rd/Casual Gourmet Hi Dianna, The company is hosting a serve safe renewal class for everyone who has/is expiring in January. The private class will be taking place at our shop on December 3rd with a test date of December loth. Unfortunately until we have completed the class I will not have the new certificates for you. Please let me know if you have any additional questions. Thank you, Kelly Kelly Field Senior Event Producer &Senior Cake Design Specialist The Casual Gourmet 31 Richardson Road Centerville, MA 02632 (508) 775-4946 www.thecasualgourmet.com i COUPLES,CHOICE AWARDSO 201,8 On Mon,Nov 26, 2018 at 3:33 PM Bellaire, Dianna<Dianna.BellaireQa town.barnstable.ma.us> wrote: I want to correct my statement below. The Allergen Awareness is fine. It's the Servsafe Certificate I need to get from you for Marcus Dupuis which expires in.January 2019. If you have another Servsafe person.or a new one for Marcus that would be helpful. I apologize for the confusion. Dianna Bellaire Permit Technician. Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.B ellairentown.barnstable.ma.us From: Bellaire, Dianna Sent: Monday, November 26, 2018 3:23 PM To: kelly@thecasualgourmet.com Cc: Bellaire, Dianna; McKenzie, Marybeth Subject: Food Permit Renewal 2019/31 Richardson Rd/Casual Gourmet Hi; I received your application for the renewal of a food permit for Casual Gourmet at the address above. The Allergen Awareness Certificate expires in January. Do you have another person with Allergen Awareness that expires later? Has Richard Goudreau taken a new class already? We should get a new Allergen Awareness for this because we are renewing for the year of 2019 and it is so close to the beginning of the year. Please let me know or send me another Allergen Awareness to this email, by fax or by mail. 2 f -PERMIT N10: ` WOWN OF BARNSTABLE 12/28/2005 286 BOAS DD LTH PERMIT TQ _R T GOD.. ST 4BLISHMENT In accordanc �' it �tio� ga it of Chapter 94, Section 395A andCgapeettfi5f ftleb � t s;; rmit is hereby granted to: '. ek OLIVE CH4iVOUAL GOURMET ; Whose place of business i' 1 ICHA, XRVILLE V­226 �. AType of business and an r strlcti ns: BLISHME� T " To operate a food establ" mkrl't i the a= N L f RESTRICTIONS IF ANX. �. SEATING: �� A UAL: YESF SEASONAL: ' R-(: FEES D OF HEALTH RETAIL FOOD STORE: s �, FOOD SERVICE ESTABLISHMENT: c0 i0o a Miller, M.D., Chairperson Smner Kauffman M.S.P.H. x` RESIDENTIAL KITCHEN FOR RETAIL SALE: , , RESIDENTIAL KITCHEN FOR BED+BREAKFAST: f Paul J. Canniff,D.M.D. "' MOBILE FOOD UNIT: et fQ TOBACCO: FROZEN DESSERT: " CATERER: . ' Thomas A. McKean, IRS, CHO Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE 4 . �a .Pd v. ,.t • y xa Est� " s Y yy i U � ;4"yyy��� �c t blown of Barnstable Regulatory Services Thomas F.Geiler,Director BAWSTMLA Public Health Division Foy 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: A ( NAME OF FOOD ESTABLISHMENT: ` A))RESS OF FOOD ESTABLISHMENT: qt1QAJM�2CL62m4oud1e_., MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP:.... PARCEL(S) TELEPHONE NUMBER OF FOOD ESTABLISHMENTi (��j,7 _G{� NUMBER OF SEATS: INSIDE: . ;�6 OUTSIDE: �^ TOTAL: TOTAL NUMBER OF BATHROOMS: _ ANNUAL OR SEASONAL OPERATION: TYPICAL HOURS OF OPERATION MON-FRI: : AM TO : DAYS CLOSED EXCLUDING HOLIDAYS (I.E.MONDAYS) �f M Ck/4D IF-SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO SE ASONAL.ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY /FOOD SERVICE =RETAIL FOOD BED &BREAKFAST CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING ; (OVER-4) Q. ealt kpplication FormsToodappi.doc L` ***RENEGSDER*** IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DININGTID IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOORS)? CONTACT INFORMATION: n FULL NAME OF APPLICANTC� - SOLE OWNER: . S NO ADDRESS PHONE#L�Zb ia� IF APPLICANT IS ATARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 0 - lI -7/c STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DON'T PREPARE FOOD AND CONTINENTAL BREAKFAST): , LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE.ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION'CERTIMD STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS -ti OF OPERATION.***PLEASE PUT THE- NAME .OF THE ESTABLISHMENT ON, THE CERTIFICATE*** ll nQ�X`� 1. L Qd11 EXPIRATION DATE: / / 0.6a , 2. 6d4 EXPIRATION DATE: 3. Loc;!e4k EXPIRATION DATE: ,/ / 4. EXPIRATION DATE: / ; /� SIGNATURE OF APPLICANT AND DATE QAHealth\4plication Forms\Foodappl.doc �Nalne'of Business: Address: L Owner: # Seats and Standing Capacity: Indoors: Outdoors: RESTAURANTS Approved Denied Floor Plans— Received, Staff Meeting Review Date: Application form In-ground Grease Trap or GRD with a variance. F Sewage Upgraded or Town Sewer Water Supply- Approved Source, if well, annual testing& licensed Operator Handwash Sinks—location, number, design and signs Touchless fixtures Three Compartment Sink and Dishwasher (high or low temp?) Visual or audible device. Test strips, Log Book - Low sanitizer - Type of Sanitizer: Quats, Iodine, or Bleach? (Show storage Location on Plan) Mop Sink—Mops to be hung properly and dried Frozen Dessert Machine (Dairy) Yes No Drain Boards—air dry utensils and equipment Ventilation Systems for Hoods (Cleaning contract) Number of Bathrooms Proposed: 1. Touchless Fixtures 2. Ventilation.Systems 3. Self-closing door(if located off the kitchen) 4. Soap Dispensers—Mounted 5. Paper Towels—Mounted 6. Handwashing Sign 7. Women's Room— • Covered trash bin or sanitary napkin dispenser Floors, Walls, Ceilings (Smooth easily cleanable surfaces) Lighting—Sufficient/lighting shielded Refuse containers Covered (sufficient number and size, durable easily cleaned, insect & rodent resistant) Dumpster impervious ground and blocked from public view. Touchless sensor-operated faucets at restroom sinks. Touchless sensor-operated faucets in handwash sinks in food preparation areas. Dry storage room location shown on floor plan Lockers for employees in designated area. Poisonous or Toxic Materials (storage located marked on plan, labeled containers) Cut Sheets (for all food equipment) Screens for Windows and Doors • Plan approval shall be granted or denied within 30 days. • This list is not inclusive of all Federal, State and Local requirements Q:wpfiles/Reskitl0.doc ea-ate EXISTING FLOOR PLAN Tad, b' 3,�Qe V4"u1•_p"SCALE SHELLY E.CINSE TE 0 WALK-IN w� WALK-iN :CANOPY F R.FE ER!.- . 4 STORAGE STAIRS _ �COLVHN J i K'i•T CN E N 0 ,t. .-v-mrodad�pJ. nr�s hVt+.S uvs�ncn •�,"J� .. ' 31,_a„:.- .. OFFICE ' EXISTING FLOOR PLAN --2.1•_b 3,_pd 4/4'-4,0•SCALE $KEL.LY E.CHA.^+E ` .WATE �. 0 WALK-IN `"'� WALK-IN FREEZERS 9 Sin s - STORA6E STAI(25 COLUMN SHELVES V-O O K{.T CH E N O.NFol : �9•_ a ;woMtN 0 OFFICE ..���?'°5 apgl�re+x'� 37 _a„.. t,. pXdoidL CLOSET / ------------•a`_a� - EXISTING FLOOR PLAN i/Q" T—Gn SCALE ,p SHELLY F.CHASC l..Q. /�-A1 t WATE W GJred ALK-lN � �. WALK-IN � .CANOPY FRIF 'ERS _3 Stnl . xELV6S hr1. .534ELVE$' . STORAGE STAIRS _ COLUMN K'f•�CH E N 1 0 eH Jr r� O v rt J Fo � O J. OFFICEo co' CL c d CLOSET FE 4 . • { r 36`ti" aa'-ate EXISTING FLOOR PLAN . SMELLY E.ONSC wATE 0 WALK-IN '� WALK-jN CANOPY FRFEZER!� . , 6af .SHELVES' }1eOZj 4T-i° To .. STORA6E c . 57MR5 COLeMN ? ,.SHELVES 9'-O" j'... bTC ._.: kN E N .. o - �t�'" OFFICE bxAi 71 � _jl Aj - . __ — -- — - �� ___�- ,--,'1.-.��,':�I?'.�"�'I%�.I'"',...�.,,I.�7 I,�l...,'".--...:.'....:I..l,��..-�.-.-'F.-,�I',.:�,!...�....�I 7.,,,� ,.-,t..�.:,,.-.,.',..."�.,',.;�.,-%�1.I.-,�.F4��.-,�..�---.,'..,!.,i.:--.x.��,.:- ,:��.-I�....�,�.%��%!I..�.---�"T.�.II�,.I ,i"I'..-.��,�.j,..n-:.I.�'..,-:./':�.:�..%",,I-�,. __.. r j r j •�A�E r T 9 . ..�:.1.II:I1....II.��I�I I�,I.I..�I..��.I.�..I�I'I I..�.,�.I.�....II...I�I...I:,.,I-�.�%-..-,.,�c I.I.-I�I..1�I.I.;I-��I.�%.I....II..�II I....%,0I�.1-��,�I.,I:7..I�...,I,..�I�I II�II I'..��'.I.III.....�.-,-I.I..1".I.,.I.,.O�.�I.,.,�.:.:.1�I-,1�..I,I.��..:I-.1...I.I�.�.,.,'....1II.--,rII.�;-..1-..I;�'I,.:.I.,.�.�.-I..I.I..I,;.-.I,.1...�....-..I:...:�;,,I.I�,...,.....5,.:'.�.I;,,I..-i��iF.�..:.;:".:.:.1N.�I;,i l.-.(;..-.�.I.*..I':...'I1.'i.I�l.�,:..-�I..-IIi,'.\:,vI,'.��.,1-i,..�.m..,��:.I:.�%-".:-.,�,!..!I.-:.,I�I�......--.:�j.;1�,'I'-.--j'-i,".r.�I.'"—�'-;.%�...-',%,".:..���.'�."—�.I1,-r.'..',.I�!'�.�I'.Ij;'.I�,...�,"�'I.�..�.I�I�,f..:.,,.-.'..i,',.,�...,,,,I-l,�.��-.::��.��,.,-���,*,,.�...i-:�,-.%,.�.-i I..,..�....(,.'—.�..I 1.-,�...J,,.I.I'.-,;,."'���.�I..'-,��,,�..�%��"-';..,:-.'.l"I�.I-�q'-�,,i..I...eI�,..-I��r,",'.I.:-.'-,..%I'..:l:...L:1.....-�-,;..,;i.'�.....i�""-,.,I..'�l.'I,:.;II'I%�.I'�..'....1����.��'.,,:.i��.'.-,.�.-�.'q�..,�-�',�.,IW;�':..�-.—:,-.��A�;,.:.,�,I�!..-.I�i-1'-�.,��-'�..:---:-Z'.'L',::.I�--I--"'�',`.I�-:�-.�-;'�.I,I�;.'-.I..-,.,,,I,.-':.',I'�.�.-I,'-�i1..I.�...,�',--�--.I i'I z,,.���'I,�.,,�.II1."��4,��I.-..'-.z.,...�.�:II.-1��i..-�''.'��,,....."�I 1-,��..--.:I--5'-—"...--.I"..�g-",��,-_-I-.:-`..1.I".,,,."/-'.�.I r���I,,I"...1.-",,�,,�.�.I7,'.-'�-,.-%1.-�,(.-%--..I��",�.�-.�-'J'"-t'%,��-1,-',�i,,":".:.!..--,..�...I�....I...,.-,..I:�.-.�,"�I.--&-,.:I I..�,:.�:i.,.'I,.-�.',.:.,,:-:'.I:-".—:.-.I1.''-'-1..'-.��'I�......",,"1t.-:.,.�.','-1.��"...,I1I--.!--I;�-..%-I 7'.."-.-.1.-'7.I,;.-.".,'�-In-�.��-�-.�.'I.,'...��-'.�-I I!�'.-1--:��.1.-.'�,�-,.�,'�,.:Z`--'�I I'�I-:.I'.,.��,,I��",..�,,'I,-A.�0I'''.I,.,'�1,'I�-�.,6��"';�I,."I—.�"S"1:I��-�:I-',1 I-�l.I,.�.:..�.�',��-.��.:I,--.,�:I"-I.���,'...%*7'..,,..."',;;:',1--I L,�,1.�1.,�j.:eI-,,,--.-,��,,,,,.�-11...�.�'&..-'.1,%.I::..�.'I I1�I--,2...:":I,'.�.1.,-.�-1�-''�.-:.'"..�.'�1�-,;.5.1%!,:..I.�%I-,�,...''.''.�,'-"..r 4,..,,—I1--'...I x.0'.:I,."'"..,'I,-�e::".:....11,.�..1��:.1�.�..i--.-t,-,1.%-,.--.�-"'�.,I.�.�.�,7.1,�".�.��"".-I',,.I....,44:..II.,,,'�"........."I.-,', i{rr Y "-, f `S t r h y 4 f '.s . " 5 _ - - r RU - r p s a:. ✓ - ' a [aces Nor .'w 2000rT \ - w - _ 7 / G ..:� .S' 0/ .SZ S I �� tl�j L�✓L.. !, 1 VI! . ¢g9.. 5' \ •/ �� s s r \ / �\5 ' } b ti\77 jl. f S ! ..ICY' Isr r ,- , ;; t \� - �_ _ - nI rill ,.�`c - �,a t \ 31oI _' :-. �- r\� .' ` Sao- •l 'ir i_ I. rr S� 1 _ i•.. 5;a -.r v :. I ° v i .1 ,-f - i A. l �. � I . _- ,. ..;' A" ,.r '�-. ` -� / -Sgv ter'-'._ c -`' o"< �.�'b� r i _ _ Z, - c Is i y o { cg,N,, 5 04s , . of cca . - _ .. _. Y .A _�.,.,.o _ Sj� cr `s y / t r.;. ty o '` 3 .:, �. pl eE : _ 3. .. -/ry..... .. .. .. ...... ..., -......_ .l ,..,, _ o a.. 7 J' r- -- — - � -! �! 1) E' P ,r f _ �i , a f i .-�,�-�-I..�,.��,71'.,-4;�,'I-'...�;..,-1.:.,.-;.O\I,.�',_,,.,..,,�.V�..;.I.'I-,"�..-:..'-''-1,,.,�-.k.�,,,.,.1,i'��.Il.�.-,--:?'',,-l.:'.!.,%....,;I-k��"I1...r,-,.."iI 1:�"....�-..:�.'�.'.�1.�.'.��-.I 1,-�,..-.�'k--.,,-"*�p.�.-5i.1�.�.:,�.,.I,�-:..,,,�A.�T i':'..�..",....-1.'.��I"�.-"-",.,,,�..I.-.'�.,:.:'�,�-\.,..'�-,"'�"�".:*.,�;1,.,�z'-.-�.I;�:­f��..�.-*�-'-I-/.,�.,.-�,-..,1����-'.-I�-�,�-"�,'��.'�..,..,,.�1�i I-IS',1�,,-.,,I',:.,'-,1.:,-I::.�'.��..,-"I,N..,�-,�w�,1,-i.'.::,O,:'.-.�,,:�I.I1-,1 2��6..i7.�I-;���..I,�.�,.-�,"-..".;'�:l-l.-:�'%...�z-,'.,,,�I.�w.'I!,�,-1 1.,1,-V.,...-�'z�Ti'�-.,..�2-.,.:,'�.:.1,-�,.,.':.,N,,-.W,���I II\I�.n.-"-.1...',��':1,,.'�1.��.-N-.�,,i..'�,4.%,-�.-..--ii,.::.I%m.,y,,-:.-...."-p-"�I ioiIItI.--""-... 7 `sz \ t 4' - r r t ' < . t - 'T 11 i e ! ;. t 50,. S 5 to (i 1 / 49 i i p - S Sec \ 2. /" �� ::.! y : 5` > r rl K z h Al/,, ? i h:: 1 w 5° �' II ,l •` v.- tENTEK,w_ f.3f e?PSf.�:/:f� e,. -!- st.. i/ E.: 1 t'.is t,¢c 1'8.:. d F :! ,'; -t, r \ :�'.T. -�S„•. _ t, r b 't r3 X I. [ r a . a . I R.E/YZ ,�s - t .;..�...s 'CP n T../, . ..:: .'..,, - ,�:cxE:. ., � L/O '. a �M! r , .`.. , _ .: ., - - . . r 1 ' ..:pia aE.?}'� ',': j.,. / - d r .J'. -. 1. �tr�ecr `{! 1 t r -, 'ar a F i, JN 3.`t g f `//_ r� f �c .r in• O r :..a- a j - I. -, L z Y-S"p �:.; �G Zo/t'.. .S�r t Y. - ". b -- ---— t y — - - _ _ _�` :. '/ P! lti ...:. -. �. : ={r.t 'F�,f/Nc.F�K.� g, '.1/�YE70A'-,. 1 .f..:: :g.,;.S r'. n • $w Rs�Y.' brla hf,� fir,..r {. TG:.k - ',. .. ... Y t :.... 1. .: t �j:: •f •'l, r,,�. `:' :.:T.iP I l;- 'v T 3i No'M.AIM S:.. . l .. :. ,' ':yYShr _ S 3 Y itAl+•.y9H iirsFss. ,, d . �G7�i..P . .. s Q a 1�`t q-_. J _ -_ _ - _ . L- _ >': - s t :. ,. , =- S elownof Barnstable Regulatory Services Thomas F. Geiler,Director • aasxsrest�, . c� � .,'�'V 9 ,s6 9. PubhcHealth Division ��, ;�� ' Thomas McKean,Director l l 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: 3 'a� NAME OF FOOD ESTABLISHMENT: Ott V ej C f ± ADDRESS OF FOOD ESTABLISHMENT: Ob 0) MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: �PARCEL(S) - d TELEPHONE NUMBER OF FOOD ESTABLISHMENT: NUMBER OF SEATS: INSIDE: (? OUTSIDE: TOTAL:. TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: 11 VaL TYPICAL HOURS OF OPERATION MON-FRI: �_: 0 TO Ob DAYS CLOSED EXCLUDING HOLIDAYS (I.E.MONDAYS) S)fi qs IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY CD OOD SERVICE N - CO RETAIL FOOD BED &BREAKFAST CONTINENTAL BREAKFAST rv ' A RESIDENTIAL KITCHEN N) MOBILE FOOD "o TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVR Q: a1thl" Ur-ationFormslFoodappl.doc ***REMINDER*** _ IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE BOAR90F HEALTH AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? , I Q r IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? t CONTACT INFORMATION: /_ FULL NAME OF APPLICANT (��r VI C,AA SOLE OWNER: YES /NO ADDRESS l!1 I S t 1 h t Jar . PHONE #(A) ,- �a 4S .IF APPLICANT IS A.PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL -PARTNERS: , IF APPLICANT IS A CORPORATION:` FEDERAL IDENTIFICATION NO. 3� y STATE OF INCORPORATION I�l� FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DON'T PREPARE FOOD AND CONTINENTAL BREAKFAST): K LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 20049 EACH FOOD SERVICE.ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE- NAME _OF THE ESTABLISHMENT ON. THE CERTIFICATE*** 1. MILVA EXPIRATION DATE:/ Z 9/ a& 2. IlAdl T EXPIRATION DATE:/ !iU JT � 3. EXPIRATION DATE: 4. EXPIRATION DATE: /_/ SIGNATURE OF APPLICANT AND DATE Q:\Iealth\Application Fcmu\Foodappl.doc LOCAT-19 ,•� SEWAGE PERMIT N0,fl-&(,1 VILLAG�E,,�( IN ALLER'S NAME AND ADDRESS BUILDER OR Oar -DATE PERMIT ISSUED DATE CCMPLIANCE ISSUED o i y �i"o r- No....81;.3! ..... y Fiziml...3..Qp.......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ......................... own---.....OF........j agrnstable........-...... Appliration for Diopogal Works Tonstrurtiou - prutit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: .11e.,...MA.....Q2L32- --..H...&...0,Zak=...............•------------•----...........-----................. Location-Address or Lot No. Je.-•an-•Ren. i ...z ......................... .......................... - : Heech�raod.Ian�.,...CnterviLl e,. .A2b32....- ... ... -•- -••... Owner Address W A & B Cess ool Service................................................. 128.3ishogs..Terrace.,.--Irannis,..MA....D26D1---•-- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of persons............................ Showers YP g ---------------------------- 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................ Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.. ---•-•---- .........•-----•-•------•------..•---.... Date Test Pit No. 1................minutes per inch Depth of Test Pit..................._ Depth.to ground water....................... 1� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•-••-----•--------------------------•----...---•-----...........----................................--...-•---...........-------•---•--•---......---•---- 0 Description of Soil.......Sand ..................................................................... ----------•--•----------•-----••-----------------------------..._....-----------•- W ----------------------------------------------------------------------------- --•-••---.............--•-•--•--•-•-----•----------•----...-------------------•----..........------------........ U Nature.of Reppairs or Alterations—Answer when applicable..._insulation,•-oi--a__1,.Q.0.0..ga11Qn.gx.-.east, stone...Packe.....(extra stone •leach_pit..(Q)E.Qw).A-------------------------------------------------•----•--•---•----•--........-•--•---•---. Agreement: The undersigned agrees to install the aforedescribed Individual System Disposal Sewage stem in accordance with Y the provisions of iITLL 5 of the State Sanitary Code—The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has been issued by She boar of 1h th. Signed --..---• . ----•• -= .: ........7 $<$1 ate Application Approved By....... . --••-------------•--•. -------- 7 W1.--•--- ......._.._. Date Application Disapproved for the following reasons---------------------•-•----.....----•-....--•-•-....._..------•---- ............................................ ...............................•-•-•------•-----•---•---------------•-•-•-•------•-----......------•-•--------•-=-•--.......----••----•-•-----------•---------••----------•-•---....................... Date Permit No.•-•--•-•-•-••-•.....81- ..... ........ Issued............Y•-8181•-••-•--•-••--........•..... Date 01 r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T own--......OF........Barnstable --------------------.................................... Appliraation for Disposal Works Tontratrtton Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: --02632. H..&...K.... @ Y.... - - - - .....--•- Location.Address or Lot No. � �I7l..Rext ...................• ..... QChwood ';-�s .e.. e�.. ....02632,----...... Owner Address aA &,-B_Cesspool._Servi.PQ................................................. 28--Bishops..Terrace-�--Hyannis,--MA_ 02601_.... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .......... No. of persons ....................... Showers a YP g ------------------ P ( ) — Cafeteria ( ) Otherfixtures -----------••-----------------------------------------•--•----•-•-•------•---------------------------------••---•-.-- ------ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench=No. ..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No.'2................minutes per inch Depth of Test Pit.................... Depth to ground water................... -•-....................................................................................................................................................... DDescription of Soil-----� ----•-•---••....................••-•-..._._......-•••---•--•-•---•--•-••------•••---•-••---••---•-••-...-••-••--•-•-•-•-----••-•-•......_••-•--........ x c, •-••-••-•---------•-•--•-•--••-••--•-••--•-•••--••------•...-•--•-••••------------------••.....-•---•-•----••••--------••••••-•-•-•--•••---••--•-•••-••-•----..........-••---•---------•-••--•---------- w UNature of Repai s or Alteration —Answer whenapplicable._.,-installation of a 1.000 gallon pre-east, stone hacked extra stone leach pit...overflow . ............................................. ` ------------ •------------------------------------------•----------------------------........._....--•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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. ±) Y Signed L t'PF� rr „ �.._ - `� :y� ':`�� 7/-8/81...... ............... .. ................................... - Application Approved By.................... ' . ----•-•---•.... ................. ••-----•--------7/at/81.•.... { Date Application Disapproved for the following reasons---=------------•---------•------...------------------------------------••-•-1................................ ..............•---------------------------------•-••------------••--------------•--------...--------•-•-.--•-•--•---••-•-•-------•--------••----•----•-••------•••-•••--•----•-•--••------••---••-•_.... Date Permit No......................81` _......---•--------------- Issued.....--- 7/•-8/$1 _ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T own.....O F...Barns table ............................................................ Trrtifiratre of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System construct d ( ) or Repaired (X) by A & B Cesspool SeTvice�_128 Bishops Terrac®, H�rannis� MA 02t;01 Installer at...Richardson_ Rd., Centerville, 02632 - can Renzi - H & K Bakery • -•--•--•-••-••--•- . -•---•---•--•••-•••----•.....--•---•-------•-•--•--•--••-••--•................ has been installed in accordance with the provisions of T �'LE 5V'T'ie State Sanitary 7 s described in the application for Disposal Works Construction Permit No.-� .............:................. dated___..---./-_-��81..._--___._.......•...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE \�. SYSTEM WILL FUNCTION SATISFACTORY. � { DATE....................7�`e I H..•---•----......-•-.....------•---......... Inspector............. ,: ....................................... i THE COMMONWEALTH OF MASSACHUSETTS I� BOARD OF HEALTH Town OF............Barnstable ............................................. No...81.`......... ..... FEE......$_.5.00... Disposal Works Tonstr Lion rrmit A & B Ces ool Service 128 Bisho s Terrace H nnis MA 02601 Permission is hereby granted----••-----------------------�I?._........--�--------------�-----------------•------p-------...------......e.----�......----�--...... to Construct ( ) or Repair X) an Individual Sewage Disposal System at No...Richardson Rd.-.t__Centerville r MA 026 2 - Jean Renzi - H`- & K Bakery » as shown on the application for Disposal Works Construction Pg ".r 7/ $/$1 2X(1; •----•------••-•-------------------•-------------------------•------...........•--•-••--------•••....-•- DATE 7/61 Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 6� No.. •.................. /1. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH � '2,... OF.........X... Application -fur Di.ipuutt1 Workii Tomitrurtiuu Vrruift Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal S em t ►��9 ► c= (%Xra--l.. ••.......••••- ------------------ ........`�o-r i----N--o --Address . .---•--•...................................... �A------ c_V..U_.lr ..-...-------- ► ®� Cy.� Owner c Address ek. Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms---------------------------------------.-__-Expansion Attic ( ) Garbage Grinder ( ) Pq Other Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------ - W Design Flow... N.5 nv...._..__._.�gallonsSer person per day. Total daily flow............................................gallons. WSeptic Tatik.�Liquid capacity-�s5-____gallons�ngth................ Width................ Diameter................ Depth.--------------: x Disposal Trench—' No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No ......... Diameter.:-_...,.2_._._ Depth below inlet..... Total leaching area.1/3_._.-__-sq. ft. Z Other Distribution box ( ) Dosing to k ( ) ~' Percolation Test Results - Performed by.__.,). :h---- _���_. .. Date---------------------------------------- W Test Pit No. 1................minutes per inch Depth of Test Pi -------------------- Depth to ground water....___.-_____.._... Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-:.-.-.---_--------..._. --------------------s......................................................... ----------------.....-------------------•-•-••---••-- ...................--------------------------------------------------------- O Description of Soil--- P . --•------- --- /�Rhen �l�-•!_.....te !------`--'-------------------------------- Nature of Re airs or Altera ons—Ans applicable----------------------U P -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 isG�lied by e board of health. L— w Signed --------------------- ------------------------ ----- ------- -� Date Application Approved By-•-• -�= ��� 9 L = ��-------- Date Application Disapproved for the following reasons:---------•------------ ------------------................................ -------------------------------------------------------------------------------------•-•----------------•----------------------------------------------------------------------------------------------- Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH. OF MASSACHUSETTS A Mr BOARD O HEA TH ,. -Cf'' t. ........OF.......... „ ................ Ii ti � -for Diipviittl Hlorkii Towitrurtiott Vamil ,..Application is hereby.'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at --------•--•--------------------------------•..........=----------••• ----------------------- .......................................................... -----•---•- - Location-Address or Lot No. ...............................-7----------------------------------------------------------------- ........................'................``'•••--••.............................................. owner Address, W .( + •----------- ---.. Installer Address Type of Building Size Lot----------------------------Sq. feet Dwellin —No. of Bedrooms....................•_.__._..._.._ _...:;.Expansion Attic ( �) Garbage Grinder ( ) PA Other ype of'Build.i-rig ...'........................ No. of persons..-__-__---______________.__ Showers ( ) — Cafeteria ( ) P`' Other fixtures . d W Design Flow--':. ..................... 1111ons person per day. Total daily flow__________________________________________ gallons. 04 Septic 1 nh; Ltquld ca�lc tv Is}""gallons �gth -_r____--____ Width_---_- _-- Diameter_-_-- --__ Depth---------------- t" x Disposal Trench No Wtdtlr "fiToial Length....._.. Total leaching.area_... sq. ft. Seepage Pit No,_.-_ Diameter_-____/��---_- Depth�'rbelow inlet...__._......... Total leaching area.. �_ sd. ft Z Other Distribution box.(' ) t` Dosing tank ( ) t "- �-, f • I�ate--------------------------------------- a Percolation Test I2,esults Pet�`formed by - .__.__.t -..-----•-__.._._ •____ --•_.• Test Pit 'No. 1W .T ,r mtn It per inch Depth of lest i'it_.__.______ Depth to ground water __ _. t=, Test Pit No. 2___. minutes per inch h,Depth.of..pc5t I'it._:..._._._ Depth to ground water ......................................................... O , Description of Soil c --- ------------------ --------------------- ............. _.___._____._ __________________________________________ _______r . . �; -'ks_..t t - ... ...-. _. ._._�. _______ _____________ ______________________________________ ______----------______________ _ UNature of Repairs or Alterations Answer when applicable ._;_____________ ______________ '__._..,.__._... __ _ .......- ......... - ---=-------------- ------------------------ -------------------------=----------------------------------- Agreement: l The undersignrid,',agrees,to install the aforedescribed-Indiyidual Sewage Disposal System in accordance with ,:.. they 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 the board of health. Sign. Application Approved By.... - t4 '' "'i ---------•---------- --------- ---. . Date Application Disapproved for the following reasons: ------------- ----------------.. ................................................ -------••••- -----•-------------------------------------------------------------------------------------•-----................................ ---------------------------------------''=---------------------------- Date Permit No.............................=.......................... . Issued...................... ................................. Date 3. THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF EALTH r .........O F................ ......✓........r!....�� (11rdif irtttr of Zo mp iaurr T IS 1 0 CE FY, Thai the Individual Sewage Disposal System constructed (t ) or Repaired ( ) by ..• ......... t Au at_.... taller - ....................................... has been installed i accordance with ithe provisions of Arti YJ of The State.SanitaryACo as dperibad 1a.1he application for Disposal Works Construction Permit No..... -- dated ..-_-_!?!_._� '"__ ......... THE,ESSUANCE``OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE TFIAT TIME SYSTEM WILLFUNCTION SATISFACTORY. DATE Inspector_ ;- •-------•---•--•---•-----.._ ----•-•-•••---•- THE COMMONWEALTH OF MASSACHUSETTS . ;. BOARD HEALTH .. .....OF...... . .� No............... 41 FEE........................ 2,Z,el ttT, tr r i it rrtttit Permi's`sion saereby granted---'-. Tt ---- -••----•-----•-• - ----------................................................ ................... to Construct or Re t (' a In vtdual Sew e �tspo. yst OV ,�'[ r �. street as shown on the application for Disposal Works Construction Rer t o._._ Dated.__. _ .....'__�_�_•... .. ............. ------------- r Board of Health DATE........ --------- ------------------------------------------------• , FORM 1255 HOBEIS. & WARREN. INC.. PUBLISHERS - Ak o.-�- ... O.�2fP Fps.. ...... N . ........... THE COMMOhW"] ALTH OF MASSACHUSETTS BOAR® OF HEALTH .. .... IL Aer ..............................7_094 .................•••................. ApplirFation for Disposal Works Tonstrurtion Vamit Application is hereby made for a Permit to Construct ( I ) or Repair (V<an Individual Sewage Disposal System at: -&r. )z < <nA�f RP C�.✓,�-�•�'�_v l-L F .... .._ .............. • --..._........... .---------••••-•--...---••---•••-•-••-•......••. Location-Address or Lot No. -....c orTZ ......... s. rf�s .✓�✓ s �.�r Owner Address a --•.................... ......--•----••--........-•--••----•-•••• ----•-•-•-•--•••----._ ...--•-.....---•-•---.............._...--•- Installer Address 3�53 Type of Building Size Lot..___._..45 ........... feet U Dwelling—No. of Bedrooms.............. .....Expansion Attic ( ) Garbage Gpindrr-E--) Other—Type l�o fi?, o. of persons `"'.............. Showers C p., of Building ............ ....... �'1V p ( ) Cafeteria-(- ) Otherfixtures ......... --••---•--•-------••••••••----••-•--•-••••--...-••--•.....------.•----------------•------••-•-•---••--•--•-•-••••-••..................•.---- W Design Flow...............................•...._._....gallons per person per i day. Total daily flow................. 3..` ..�..........gallons. �� WSeptic Tank—Liquid'capacity-A'STjallons Length---17._-..... Width......7........ Diameter................ Depth... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... --______-. Diameter.....1.`f.__...... Depth below inlet__�!�2 5.�__. Total leaching area...�72• v sq. ft. Z Other Distribution box (3) Dosing tanj:;.� '-' Percolation Test Results Performed by.... r. . S �'��' Date__.�.'� .. 3� 8 ... Y --------------•- ----•/ ; ,al Test Pit No. 1..... ...3minutes per inch Depth of Test Pit----f........ Depth to ground water....... GT,, Test Pit No. 2................minutes per inch Depth of Test Pit----_............... Depth to ground water........................ a •• -------- --------------1 ,..�..................-----------vr---------------------- -------------. O Description of Soil M_ i ^^....s!!n r✓ J/�... s a !o G D r L)---------- ---- ,/ XT---- x -------------------------- •------••--•.........•-•----------•------•-••---••...-•--•••-•-•-••-•---•------------••---•--------•--------•---------•-•••-•••••-•-•••--••-•••......-•--••-•-•-•-------•-••- CS s .......... � .�...._.Z.o . 0-7-a v�.... ............... � E� !�-�-------j�Y,s Wit..,. .... asa Agreement: �P �-a t o 1�e 9 i S e '�•'c ati n :• w'... e, •n C ea s -.e The undersigned agrees to install the afore escribed fridividual Sewage Disposal System in accordance with the provisions of TITLE 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 h lth. Signed..x...................., . .. .-- --------•--• ..................... ',�Q Application Approved By.................. ••--•- .. . .. ---•-••-- --•-•-• ........... Date Application Disapproved for the following reasons:................................................................................................................ ..............•------•----------------•--------...------------------------•---------------------.......-- Date Permit No.----_._�---�` ._-'��.......1.2-... Issued....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) m A DATA r No. ....�...� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -_. ........... Appliratilan for Uhipos al Workii Tonotrnr#inaa rmnit Application is hereby made for;a Permit to Construct (I ) or Repair (V') an Individual Sewage Disposal System at ........_... ...- ............................•...............------•---------- ------•-•-.•---- ..--•-• • --- ----- • -• •- 1 Location-Address ,r or Lot No. f% T .?,? i.�J - .ice .= L .. C7 i7 1 `Y .. .a.....i�✓ ._._`�.. �`.'' J- %'i?-, //t// _S /I�''��+}.. ........._. .......................................... ..........................•___.._.__......_....--..................--...............-----......__. Owner Address a ...................... �•:------------------------------------------ -------------------------------------------------------------------------------------------------- nstaller Address _ Type of Building Size Lot_-3.... ... (-..Sq. feet Other—Type e of Bedrooms. edr ................................ _ . . ..........Expansion Attic ( ) Garbage Grinder-( ) a Other yP o. of Bedingms---------------`-:--- _�No. of persons........_.--.............. Showers ( ) — Cafeteria ( ) Otherfixtures ------ -----------------------•-------------•--------•-------•---......-••-••......--• ----.•••••••-••••••-•--••--•-•-•--•--...........•--•--•--•--- W Design Flow................................... ..._ ---- � _?....gallons per person per day. Total daily flow._._._.--.--..- __---_ -. _.______..gallons. WSeptic Tank—Liquid capacity °Cgallons Length__!-?_...... Width....7.. --__. Diameter................ Depth..:!-_--- a. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....�----------- Diameter...!.'.. Depth below inlet..!....... ...... Total leaching area..LZ.�S...sq. ft. Z Other Distribution box (,3 ) Dosing tank.(—) '-' Percolation Test Results Performed b F ............ ..........•• -•---- Date f 3` �= _= Test Pit No. 1... z minutes per inch Depth of Test Pit---- ......... Depth to ground water...... " ..____-- G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •------------------------------------------------------•-------•--------.......................................-----..........------......................... Description n of Soil.... . - = " - I �' .. _ ... l .U ....-••-----••••.....................•-`-��•-�•—••--...... --= ......:. ............•..............----_.................................._ .........-J--............._ W ..•-••••................•------------•---•-••-•••-•-•--•••-•---------------------••••••........._..•---••--•_....._................................................................................... U Nature of Repairs or Alterations—Answer when applicable-----�r......_...�' ti ....................^:z.._...�U �_ .. c_ Agreement: _ The undersigned agrees to�install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL: 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. r Signed•-= --- ="z""_ / -e -...�/� ✓�/r J ..�.. _..................................................... 7 v / y( r _? y / f Date Application Approved B i__ 1/ �/ PP PP y - - w j .• � ..__.._..__................. -$--1- r ..... �:„Da e Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•..... ......----•---•------------•-----•..............................••---•-----••-------------••-----------...--------..........-----•-----------•-----------------------------------------------------_._.._ Date PermitNo..-- '- ,.------- -� r��� Issued...•.......................................................---------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 T v ✓tom'.- OF... -:.:..>.f7., f �'..' . .� -21-/'.............. ......................... Tatifiratr of Tomph anre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�) by-------------------------tj N _ ............................... - Installer / / /_ �r)f� • ' 'I /-- s J fl � ,� t rr• �f� has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit ...... dated-------- r..�.f.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................•-------.._.........•--•••......-•-•-------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 . �.. ..".....OF.... -'........................................................................... 0 �9 N .... FEE... :.............. Disposal Worko 0ontrnrtion pamit Permission is hereby granted......................P ......... ---•----------------------- .----------- --.......------------ •--- to Construct ( r,) or Repair ( , an Individual Sewage Disposal System at No... -- -- .� --. v - Street rz�.5'Dated.•-•--• Z as shown on the application for Disposal Works Construction Permit No.................... �. .I_.._:. ............................. . ..--x.2 4k,_-_-----------------------_ Board of Health 4, DATE----- ------------------------------•-----••-----•---•-••._.__...------- FORM 1255 M. SULKIN, INC., BOSTON .\ COMMONWEALTH OFIMASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL: F3FAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 19 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: A Owner's Name: Owner's Address: y Date of Inspection: i Name of Inspec ..(plea a print) �'� Q` f Company Name. IZ �. Mailing Address:T5 Telephone Number: CERTIFICATION STATEMENT 1 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 ection 15.34.0 oflitle 5 (310 CMR 15.000). The system.: . Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail 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 completingahis inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ' re4P5 r�®fl/"y(� .1 j''� r"2 " �!I%°' i.✓ �' 1 l j P.0 ✓c�i /�y: ****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. Title 5 Inspection Form 6/15/1000 page I Page 2 of 11 .. OFFICIAL INSPECTION FORM-NOT FOR VOLLTNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) /1 Property ddress: 3 ' ;2 ,e'�a '` P y Owne r;Q, Cy!! Date of Inspection: Inspection Summary:;Check A,B,C,D or E./ALWAYS complete all of Section D A. yytem Passes: I have not found any information which indicates that any of the failure criteriadescrib.eddn�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. Answer yes, no or not determined(Y,N;ND)in the 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 exfiltratioh 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 pipes)are replaced obstruction is removed ND explain: Page 3 of I OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM PART A CERTIFICATION(continued) Property ddress: Owne Date of Inspection: C. Further.Evaluation is Required by the Board.of Health: I 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 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 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 l of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and.the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: Owner ��) A_p Date of Inspection ?3, r.)00((q 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 i Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded.or / clogged SAS or cesspool 1/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / cesspool. — Il Liquid depth in cesspool is less.than 6"below invert or available volume is less than '%day flow. — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100'feet of a surface water supply or tributary to a surface � water supply. . Anyportion 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° ri'v is: than 100 feet but greater than.50 feet from a private water — P P Y— b supply pp y well.with no acceptable water quality analysis. [This system asses if the well water analysis, Y P performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution frorn'that facility 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.] (Yes/No)The system fails. I have determined that one or more of:the above failure criteria.exist as described in 310 CMR.15303,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 gP d. You must indicate either"yes" or"no" b to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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—I WPA).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_ n Page 5 of 1 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Ad-dress- aj Owne V�spection-, Date o � IYXI Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o Pumping,information was provided by the owner, occupant, or Board of Health Zere 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'uncov:ered, 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? V _ 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: Yes/no _✓ _ 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(3)(b)] 5 Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT.FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION e Property Adprew 4 Owner. Date of"Inspection:'.; �OW CONDITIONS RESIDENTIALO Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage.grinder(yes or no):__ , .Is laundry on a separate sewage system(yes or no):_,.[if yes'separate inspection required] Laundry system inspected (yes.or no): Seasonal use: (yes or no): Water meter readings; if available(last 2 years usage(gpd)): Sump pump(yes or no):_ V Last date of occupancy: COMMERCIAL/INDUSTRIAL. Type of establishment: Q Design flow(based on 310 CMR 15.20): gpd Basis of design flow(seats/perso)r/s//sgft,etc.): Grease trap present(yes or no):4 Industrial waste holding tank present(yes or,no): N69 / Non-sanitary waste discharged to the Title 5`system(yes or no):x'/0 Water.meter readings if avai ble:'©`1�S.d?Of� G� �'-�. jmo Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records. / Source of information: 6-9 ,66—Was system pumped as part of the inspection(yes or.no): fl 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) _Tight tank, —Attach-a copy of the DEP approval Other(describe): ' -7 Approximate age of all components;date installed(if known)and source of info ation: 1. Were sewage odors.detected when arriving at the site(yes or no):/ 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION(continued) Property Address: 14'/ " Owner: Date of nspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:Zoocate on site Ian Q P ) Depth below grade:pLCJ Material of construction: oncrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:, TX),,,,tV Sludge depth: �.r%f ix J' /l Distance frorfi tbp of to bottom of outlet tee or baffle: , Scum thickness: Distance from opop�to top tee or baffle: Distance from bottom of scum to bottom of outlet teen1 or baffle: How were dimensions determined: ' `C Comments(on pumping recommendations,Inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to o let in rt, e 1 ence of leakage, etc.): ° , � � �. GREASE TRAP: (% (locate on site plan)' Depth below grade:. ) Material of construction: --concrete_metal_fiberglass_polyethylene_other (explain): Dimensions. Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scurg to. ottom of outlet tee or baffle: 21 Date of last pumping: / Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels related to outlet invert, evidence of leakage, etc.): ad kLjay'e�'I"Af ✓._: CJ 7 Page 8 of 11 OFFICIAL INSPECTION FORM ' NOT FOR,YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION/(continued) Property Address: G° -e�" Owner: Date of Inspection:----Ig ( 4441,2 X TIGHT or HOLDING TANK: /V/U(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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site:plan) Ace4h' i uid level above outlet invert: Depth of I f P q v and distribution to outlets equal, an. evidence of solids ca o ver an evidence of Commnts note if box'is level n Y�Y ( 9 any leakaue into or out of box,e .): f � 1 PUMP CHAMBER:,(locate on site plan). Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 3 Pate 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property dress; O , J2A/ wne Date of Inspection: � � �� SOIL ABSORPTION SYSTEM (SAS): ;/ (locate on site plan,excavation not required) If SAS not located explain why: !y�Ieaching pits,number: Teaching chambers;num`6er: Teaching 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.. : � k(o � l''' • � ''�,.�y-�,�i�C. /0 " CESSPOOLS; .�O(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 or no): . Comments (note condition-of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: All) (locate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.): nn W 9 Page 10 of l l OFFICIAL INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART_C SYSTEM INFORMATION(continued) Property Address: " Owner: 1 Date of I spection: a d� c+G�Gt V SKETCH OF SEWAGE DISPOSAL SYSTEM. Provide a sketch 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. i O 7 � ��pi oo lY 0 o 0 0 � - a x p; 1 [('CpPfdj Ab -"-3 1 I ev 10 6 • Page 1 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART�C SYSTEM INFORMATION(continued) Property d•dress: Owneru /� Date Inspection:_ _L<°. d `��, C)06 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water r� feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: �7'Checked with.local excavators, installers-(attach documentation) t Accessed USGS database-explain: You must describe how you established the high ground water elevation: A 4A I 11 ' t � t Permit Number: i Date: " Completed by: - HIGH GROUND-WATER LEVEL COMPUTATION Site Location: r'.Yy/' ,,/ :Lot No. Owner: / "rat.111 _�5 111'/n Address: Contractor: kv 0//i5 Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ...:....... - ................................ ... .Date month/day/year STEP 2 Using Water-Level.Range Zone and Index Well Map locate site'and determines p OA Appropriate index well...........................:.Alf �y .......... c OB Water-level range zone ........................ j i STEP 3 i Using monthly,report "Current Water Resources"Conditions" determine current depth to j water level for index well ........................... 0Ild 77 month/Year 1 , STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) 'determine water-level adjustment ................................. ,- ...................... .... ... i STEP 5 Estimate depth to High water by subtracting the water- level adjustment (STEP 4). j °from measured depth to water _ 'level at site.(STEP 1) ;............... j . Figure 11-Reproducible computation form, 95 _ r i� i ASSESSORS MAP ISO: f Fizs.....o.0................_ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH QW►'1...................OF....l m;g !.e......................................................... Appliration for Dhiposal Works Tonstrnrtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal System 1 cation-Address o Lot No .................................................... ...............-•--� As,_.&mh uy llp.......--------....-----...........--- Owner Ad ress --------- ------------------ Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ----------------------------••-• . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.............._ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.............--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1----------------minutes per inch Depth of Test Pit---.--..........--.. Depth to ground water...--..............--... (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......---.............. a ••••••---•-••--•••...-------•---••----------•••-••-•-•-••••-•-•............................•-•--•--•......................................................... 0 Description of Soil........................................................................................................................................................................ U •--••-••••-•••-•------••••••--•-••••-••----••-•--•--------••••••-••••-•--•--•••----•••-••-••-----••-•••...-•-•--•-•••-•-•-••-•••-•-••••--••--•--•-••-•---•-••--••••--•-•----------••--••......--•-...... W ••••---•--------------•---------------------------•-•--•----------••----•----------------------•--•-----•-•-. - UNature of Repairs or Alterations—Answer when applicable..Tn? _--AP7,62C�D___�2_!t _f?%.._(._� l�q..._.. =--------------------------------------•-----------...............---------------------------------------•--. Agreement': The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T`= E 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 b board of health. to ApplicationApproved By............. ------•... ..... ....••--- -- `------..........-------------•----•. ............... --Date---- ------- Application Disapproved for the following reasons---------------------------------•---•-------------------------------------------------------•••--•-••-•-•...---- ...............................-.........................................................................I-•••-••-----------•----•••••---•---•--•----••-•---••----•--------••-•--•......-••--•......•---- Date C PermitNo.....-...: ........... Issued....................................................... Date No .-_1.t.7 ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f?4w-n. OF.l:Xrt}1�:l,.W. . pphrtt#inn for R-4mi al Works Tontrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System,-at.: { ...............•..--------------- ........................................................... --•-----•--- -••---•----------•-•--•---------------..._...--•--•.._..................--•-•--•---- (( } 1 (,� ocation-Address �'^�'/� �1 or Lot No. .......... lez it KClufc p4 � eQ wr,-4 �u l o ......__q ........................................................................... .............•.....i.................- ......._...................................................._. Address 1,.�e' Owner ------------------\-------,.__.......... .......................................................3!;o fi,I&I tt .+'i'1,.S7f e. ..7 ............. II Installer Address d Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms........................,...................Expansion Attic ( ) Garbage Grinder p.I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .............................. . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.............._._... Total Length.................... Total leaching'area_...................sq. ft. 3 Seepage Pit No-----------_--_---- Diameter-___-__--___.__..--- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 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........................ n+' -••••-••--••-•-•-•••••--•---•••-----••••-•••-•.....-••................•---------•---......------•--•......................................................... 0 Description of Soil........................................................................................................................................................................ V ..•••••••-••••••••---•--••••••••••-•--.....---•••••-•---•--••---------•--•--••---••----------•••••...............•--•-....._.........--•--••••---•-•••-•-----......-•••••......------••-•-••-•------•- ---- ------------------------- ----•---------------------------------------.....------------------------------------....•--•------------------------------------------------------------ ............. U Nature of Repairs or Alterations—Answer when applicable—T??-= t1__0_l _100Q____�P!C�'1.� / a !? ........ fit.....rc?t _lrp --•••••................. rI Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TT"L E ;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. ......�._.� r �Dat Application Approved By........................... --:.-. .-'1 �- -------------.-------•---•----------•---•--- ''''� �. - - - ----------- Date Application Disapproved for the following reasons-------------•---••-•-------•--••------•--------------------•------------------------------------------...---••- ---•••-•-•••••••----...-•-•---•-•----••-....-•--•.............•---...........••---------•----•-•------••-•-•..........-••-----•--•--•••••-•-•--•--•-•••-•••-••--••••••••-•••••••••--•--•--•--••••----•-. Date PermitNo.--------`� � ��------1 ........... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 10............................O F...... ..c,r:t *-1,l rr{o l ........ . .................................................... Tnr#if irttte of Tomplittnrr T S S TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired lV } by..._-• ?1�_' .......................................................... ----------------------•-------•------------------------------------------------------- ---------- ,,.. nstaller fir=^) at - `' '-( -L .: -� has been installed in accordance with the provisions of TTTIZ_.._ j of The State Sanitary Code s described in the application for Disposal Works Construction Permit No.... dated------- __Z-%_-____-_- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. __ -� DATE............. _ ............................................ Inspector....--- //0...--------------•---------------..........._..---•--••---•--••--. V THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LTH r r '��-- _ 10 ao No...................... FEE......`.................. Disposal Works onotrurtinn - rrntit Permission is hereby granted -.: : 7rll .v....--- to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systqgpf ------ Street �_• as shown on the application for Disposal Works Construction..�� �.s.___ e _ ... 1_ a................ V_ '12 � --------------------------------------------------------------------------------------------•--.---_.... DATE---------- ------•-I------------------•---•---••-••.......................... Board of Health FORM 55 HOBBS & WARREN. INC., PUBLISHERS tipd TOWN PF BARNSTABLE - J LOCATION SEWAGE #PG VILLAGE" Q c N ,Q- ASSESSOR'S MAP & LOToP(O $ INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 1�ovo SEPTIC TANK CAPACITY Gcyusc IceQ t co' LEACHING FACILITY:(type) ;,-- 1 •4• (size) L. -1 env iTS &- -t ow-ea NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ; BUILDER OR OWNER DATE PERMIT ISSUED: -- DATE GO)APLIANCE ISSUED: VARIANCE GRANTED: Yes No c.� '� \� _,_ . , �,1 s ' /� Ig -�C� ���5 �� � ��.�� r2oM REST 00 t` 3 Try D�9�C�RY _/ pis rA�t �A k i T, / 00 G,4 F'Ra�.c MAN- ;��`�''.,. :, �- �• ,�/_. A G'.F1t S RE-jr COMV� ROOM GAS lid _. �e9 � V LOCATION// SWAGE PERMIT NO. lei wo 4erjs VILLAGE _ A & B CESSPOOL SERVICE 128,-,,BISHOPS TERRACE, HYANNIS, MA 02601 - BUILDER OR OWNER . DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 41: 7.- �� �� �''Q9�� �� �`�� �'� � �� �y ��; � � �� .�. ,, �. � �' . � . ,� �6 � '�� -, � ��'! �� � . LOCAT ON SEWAGE PERMIT NO. ov VILLAGE A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER �a r 'A) 71 Erf'- ���v s c�Elyi E1�T � o,eP DATE PERMIT ISSUED .:���8 S� DATE COMPLIANCE ISSUED S,ystern '�2 'Doo RS tt y v� n \ D ` O Se 't K �boaga� Anew • �CCOh pit 14 l000y�/ THE COMMONWEALTH OF MASSACHUSETTS 22 BOARD OF HEALTH 4J r .......�0 ✓L-".,.........OF...�? -'-''�. L ............. 614 Trr#ifiratr of Tootpfiattrr THIS IS TO„CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by............................. ................................... --•---------------•-•-----•-----•---............---...-----•-••------•-.....-------•--•-•---•-•----•-- v at. •y J` 'Installer ti � e fi---------2 S.. ---•--. . rL '��� ...... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...z,.�`�...... dated.........I..z ___ s-t... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NTEE THAT THE SYSTEM WILL F I � SATISFACTORY. DATE..............................:_, Inspector ........................... Z— cz / L A (1 { a+ J �© I . ,s- 7 7' O�fZsL� - tZ ' 4.2 S- Z• M L-D! C//+.') �� , . SAS \� ,, �. �,= >.,✓�� \ A v' r f } - }� - �rPV ! x µ La fE54cr f! A S E// ��/JNT"E, �� a N Q^�o -� / :Ap P - pg. / � - �,/c E � \ �t 2 hs / IN `,�: ^ S �•r' ., oo ` . ; � { ;�4F; /� H,�r-� � / D C/ 7` v C .Z', �'.'Z .a .�:%r � �` C G VE'/? • R \ ti f f t�o :q!.La / � � �fi�rz� � � rx�-r •�c�: -z-- %tom «- ~ - Svc v - Yf , 4 s o Py`� $ DJ i��AgTpeV�l► y , A rs r�� IZ/e , U1 n�rl:, Co" 1/�IZ 7- I �`G_ Cmf _7 ,0'`w.✓ J - y�-11^ t� C` - ,�.a /� \ Y 37 \ �;-- .. Rr 3sc� /Jz '] mil, f t�t ". IOOQ rAL, OC ,.3Z 77 S ,/-/ r7 L i.. C O �`✓./�'O�NS T© .�A w S. \ � --_ � _ r/r rA/1/X' V 1?, C O D/W 7-/ T'[ ei' �' \ L'_ ___ __ - --- <S A 4 C+ '9 c c ,� rz o � R ry �: �(+ G7 P� tr' vN U'l _ ` ,ham .l�L] ."S�'t�77/ r. . co� � sr';z ��✓� rH 3000 'p's p,�._ Co �v s7--It �� C. '7-/ 0" 7-0 c3 �` C7 Get. , 4t.44 �L � � ?'ram i'.� E 40•94 �► =- - , ' W -4 It, o�sTv.v v ?�, `/ / .5 �,=3 g /ZT/rf ;� SE"i�7"/ C 4/. / 1 a` `' -aj 1' 35•��t v _ © 1.:)'Er.5 / a v L © Fy Z� ZI >1 .a E Z 1 G Iv 'Er-, sJ Ir7 3's•7 .� D C3 o rc r c� L o T.•5 �,�/� .� jr- Q w.P n; /i v'0'C . TC T. Yj 7-C _. _ � P ,�� x � C T L O C A T� � /[✓ O F G�� S L/nli�' 'C4 D Z) SS 0 0 .5 L•P 7-, c -A, .:c 3 c r V`t,E'.'V E A j S T/ 7-E : vs s 3 3, 0 ;:Al i / C. Ti'=3/1 tC" J D i S T. L3 � X .S) C 7t, 4G74 G,pD JD 4 - / 00O _ (2000 0-7 P.D S % O NF A L. L AfZ© IJA/ tD `^// Z 21D %-S .7- Gj -- f / D E 5 J G,ev 1.o v'/ s y.s TBr'Nel C-7 PM PLAN f= R Ca ;C-3 co.5 Tc' i�A JZ O ;I="- k v✓ = 8 3 5 F,47)T s x /S G.q c S / Z 4 S z3A TZ 7-. Z340x 7'-' /"vC? ,4L • -SE- T-/Qni� �334-lx /,S O ; 2 a•�LS) � K Z � /��ST/ T ca S .�'.�, r S 7' //�/ :n .C.. ��=-.� C �/ t� / T..S � Lam- � A 7- O�.S O G, `' ``.. IV % -s �L � � i?, GD P! L /�r`7 C t-� /�1 G 1 TS ��f2NZ !�33-3L �CE"NTF'zVIZ L� 7-- o i ,z y C- ,�,, �-- - c yArj5r-?)t4 .4 2 .5(G, 2 s'Tr q j t00 7y,\7'z J - -3 .� 'A of Mgsf _ *,=-AF/7 P[AN.ZL K 2CRAIG C O/�/ ✓� )<"T SHORT ��'7 " 7 i f 7-0 � R�r t F 7-)Z,-c4 ? T3 .N.L. / '/ 'ip JIF T' I ; R '4 f ?Z . � -� 7r 7' y+-) + F?C-1 ; 1 T ;�" T o v✓/ T H i�.� b�, �o �� P IC .brST l 7 r f2 7-7-C '`-`I /`f Fr�L T/� r? Cs,"/'.1�` . r�t�K 4 ✓i7 L Dfi 7'F /' lOMAL G L OC' vS�M.4f� PLOT PLAN PROFILE OF SYSTEM SCALE_--- _ — ---_---— - GENERAL NOTES � _ �� � _ ___ ----- t f) MANHOLE 8 COVER - MIN. DIA. 24i ' {t LOT AREA= / BROUGHT UP TO WITHIN 6:' OF FINISHED GRADE I . 4/.S } -- S; ! 'may �� 9 fNY. \ 18" DIAMETER MANHOLE WITH CONCRETE COVER f �''tri�xnPs� t / BROUGHT UP TO WITHIN 6 OF FINISHED GRADE 2. Finished grading to be done In accordance with plot plan. �:s-� ",*z�"w FINISHED GRADE 3 Percolation tests performed in accordance with the instructions to Title 5 of the G. + FG a �e •ti aap� Massachusetts State Environmental Code. �! ,� " t- / II ; , I_ I -u. _ I s - 4. All construction to conform to Title 5 of the Massachusetts State Environmental _Il=ll = _tr j„ Mom"- « MtN _ . �'1 .. I , _ 9937 I PIPE �Q Code, and the Board of Health requirements for the Town of tFl�cn� ,TfLt; INV.- 4 PVC. TIGHT JOINT P! - _.. POND 70 5. All topsoil, subsoil and deleterious material, if any, must be excavated and removed fi MIN, 6' MIN ' ' 2 > r below the leaching pit and to a distance of feet from all sides of the leaching � a•. .1 `f _ �� e 0 0 0 0 0 0 0 0 0 0 a ,� `~ t tw, 4►, I + 4� FLOW LINE t It Excavate down to inches below the surface of the natural permeable soil Ij �,�, � i I N V.= _ . 6, — c o 0 0 `0 0 0 0 0 o e e D p — �.� r --- + - °� '/ 00 0 0 0 0 0 0 0 00 e e oo Backfill as required with a clean gravel or sandfill material, free from fines, clay, organic matter and large boulders having a percolation rate in its original � ►: tNiE T %° '' oo 0 0 0 0 0 0 0 000ecoc 9 , 9 , 9 P N l ° + .� I j'I°� 00 0 0 0 o c o 0 00 o e o° location and after placement of 2 minutes per inch or faster Construct pit I ,�Cif C E•'//N. r Z©8.�f'T � � _ _SANITARY TEE - -- --- i� PC�. oO o 0 0 0 0 0 0 0 o e e ° in this material . I r I NV _ - o° e o 0 0 0 0 0 0 0 0 0 • e o ,4r! 4 E HC I OR 4., PV.0 00 0 o e o 0 0 0 o a o 0 01 6. All washed stone in the leaching field must have less than 0.2 percent material �f: ! r T DISTRIBUTION BOX o° 0 0 0 0 0 0 o a e o 0 0 0 o finer than a number 200 sieve as determined by the A. A. S. H.O. Test Methods T- I I ! OR PRECAST CCN RE E 00 0 o o 0 0 0 0 0 0 0 0 0 0 0°, and T- 27 ( latest edition ). BROUGHT TO CENTERLINE ' �— OUTLETS ° , 0 0 0 0 0 0 0 0 0 0 0 o e °o 1 r OF TANK v ° o I 7. Tight joint piping to consist cf Polyvinyl Chloride Pipe ( PV.C.) , Schedule 40, 3 t 1 0 c o 0 0 0 0 0 0 0 0 a 0 0 T- ?:- _a ,. INVERT ELEVATIONS OF ALL ode ; 00 o c o 0 0 0 0 0 0 o e �, unless otherwise noted. OUTLETS TO BE THE SAME o 00 0 0 0 0 0 0 0 00 0 0 0o 8, in cases where ledge or boulders are present, Schofield Brothers, Inc. will not be r T r ap.• 00 0 0 0 0 0 0 0 00 0 0 Qo responsible for assuring the amount of rock to be encountered. t SEPTIC TANK_ OUTLETS 0 BE PLUGGED FOR FUTURE EXPANSION PURPOSES 9 Schofield Brothers, inc, will not be responsible for the performance of this system r ,<'T//t'u ,j,�' G ,:' CAPACITY=�--__-__—GALLONS (SEE PLOT PLAN FOR LOCATION ) LEACHING PIT unless constructed as shown Any alterations must be approved in writing by PRECAST REINFORCED CONCRETE ------ ---- Schofield Brothers Inc. OUTLET PIPES SHALL BE LEVEL ' � �'�i1'��✓� r� '� FOR AT LEAST TWO FEET 10. Heavy machinery shoil not be permitted to pass over the leaching pit ( NO SCALE) 1 I . The Board of Health shall require inspection of al I construction by the design i `--=- _ -- —_--_ - -- - - rengineer or by an agent of the Board of Health, and require such person to certify ./\ � • / ,` _ PLAN_ VIEW OF SYSTEM �%,� r� K/�iro „ � .�/';; wilting that a !i work has been completed in accordance with the terms of the - - - - -. - - 0E's�4/.�! r�.f;' eE'Ct"N-= permit and the approved plans. !F;JP' c✓ r 12. No permanent structure may be constructed over the 100 % expansion area . � �D �, .' - - TMANHULE FRAME � COVER 00 13. For proper performance, septic tank should be inspected at least once a year and MIN. DIA. 24 / a tJ0000voo P P P , 00 v Sao whenthe total depth of scu and solids exceeds s the liquid depth of the tank I m , �•'' _ -- - - °o the tank should be pumped_ /.�' +4 � /�tr'rr f.v.- :-._ " M i e e. - TIGHT 4 JOINT PIPE po �00 -�" XI I� I' 4 E H C.! OR 4" Pv.C. a oo -1 /�F T/'AF' . 'f,/DUC ,O �1/ ' Tom!] MD N : " �. (SCH 40) OR I o ASE ,BE , SF� - NTi/L j/ ,� D PRECAST CONCRETE e �O� 00 -- -APE^��; �c T > ,� _ / `� r o Z_ \`- ✓ �- S A N I T A R"r TEE -t • o0 7`i,�E f;�E��T i Y E` 1��"/ Tfi' O f T//� T.E�fl 15. fJT ee Sir r. BROUGHT TO \ ' i ` ��� 0 `oU �'✓F�=''/ .� .�'7�O�1T/'/5' ri - �- CENTERLINE OF TANK l - - or o° J .y ono Oo / �JS 9f Te�e EX<:W Y.� 7/tilt/ cs /ak/!7 f� i�'C7 0 0 aoo cif` r.�1E:E 5 -�. �- �� , --- __ . ,C%E"r"�'.�'D .r -•-7,�•+� � o 0 0 0 �* �- � �-• 7'O %/V.j'!:'.�'f'" ���,C�r.�-f-'�/��7''�"' .S��'. SEPTIC TANK a � � ,,F,A J DISTRIBUTION BOX {� PRECAST REINFORCED CONCRETE PRECAST REINFORCED CONCRETE x. -- _ .ram•- .t S .>Div,. .3:r�G �'�rA� / is ��_i tom' �f!/�✓ty r _ G i Q , t ''�7"S I ( NO SCALE ) ,,.�,�, , ,, �: ��, ,�(�/N�`' •,- ,� DESIGN DATA TYPICAL- LEACHING -PIT CROSS - SECTION I Estimated Hydraulic Loading 3 FINISHED GRADE ( ELEV.Fxis:-'`) qr - 18 DIAMETER MANHOLE WITH CON RETE COVER AND f�'�'t� •����.•� ����E'>� �Fi�Lf/��r �" J�/i0 , ° CLEAN 9 A C K F I L L ---__ FRAME BROUGHT UP 70 WITHIN 6�OF FINISHED GRADE . 2. Septic Tank Size S.T. A� --� 1 .; , .�-- ..'r' ii Average doll flow - X _._.,�-_ � - 2 LAYER - - WASHED STONE - _ -- 12� MINIMUM g y - _ - �' �. - - gallons ( minimum) Septic tank provided = 4" TIGHT JOINT PIPE _-��- o + pa 3. Design percolation rite = _ M.P I. , 0 1 A Sidewa I I I oad ^a = - -- - - - - gallons / S. F. INLET INVERT - ___ _ gal Ions / S F. � ( ELEV._-----) o,; o �� Bottom p. r` ; -r o ° -- - 4 - 1 1. WASHES STONE - -- 4. Leaching Area - --- EFFECTIVE HEIGHT = �' 9 _. _ __ ' — T o _ _ Total sidewoll area provided = _ _- S F• X _ ' gal. / S.F = _ ' _ ca - ; - o --- PRECAST CONCRETE LEACHING PrT LINER OR MASONRY .• � ,�, � Id ,/1�^-r""� � i ''' �` ��•^'^' " " '-- � � _ ° BLOCKS ( 8��x Bit x 16�� ) LAID SIDEWAYS. Total bottom area provided= — � S,F. X _ __ gal./ S.F. = ---'.�---- gal. _ Maximum allowable loadin - - -� g (under Title 5 ) _ - .: gallons EFFECTIVE DIAMETER = //� . . ._._-_ __�`- - .-I i ��-- BOTTOM OF PIT - ELEV. = __`f� �'' Actual hydraulic loading = gallons R,,,O Minimum size iFaching area allowed under the Town of '`%��'�'� �� � ,q,� , � �i�+-¢'�� ( NO SCALE ) (N -j ,,,G, Eloord of Health requirements , A.0 - SCHEDULE OF ELEVATIONS FINISHED GRADE FINISHED GRADE ABOVE STRUCTURE ABOVE STRUCTURE Top of foundation = -- Invert ct distribution box inlet Basement floor = �''� invert at distribution box outlet = 98, n �+ invert of pipe at �;• 'rrq ` = i60,06 Er/STi/V<.v _ Invert at leaching pit inlet = �7 %u Elevation of leaching pit bottom = 3el�,c0 �,� ` �n.�,< Invert at septic tank inlet = _ 9e .54 LEGEND Invert at septic tank outlet = `i8 3/ _ Finished grade over leaching pit See Plot Plan rcen.T /4�T_ Sy'� XX- --- Denotes proposed contour S_- '-,q F.�o FG. = XX .X Denotes proposed finished grade r4t/0.7� //- LO - - -XX-- - - Denotes existing contour y XX .X Denotes existing spot elevation t;• 7e Amy /�vj 6 Denotes test hole location SOIL TEST DATA — - _- PV.C. Denotes polyvinyl chloride pipe (see Note # 7 above) DEEP TEST PIT I (SURFACE ELEVATION _) DEEP TEST PIT 2(SURFACE ELEVATION_) PERCOLATION TEST DATA V,C.B. & S. Denotes vitrified clay bell and spigot DATE OF TEST DATE OF TEST TEST TOP OF 12" OF WATER y cast iron _ RATE. E.H.C.I. Denotes extra heavy a v DEPTH r SOIL DESCRIPTION - DEPTH SOIL DESCRIPTION NIO DATE DEPTH FROM ELEVATION MINUTES W Denotes water, Service _ — __-__ -- _ __ _ -- -_—_______ TOP OF PIT_ PER INCH Denotes approximate property line O.W. Denotes overhead wires � c0 .� ?2'l�U T/�:��r �tJ •K �` D�'i`7'LF"T jr <"- _ b S' �E'c:�.c ;�`fC ...�,,,�n - --�----- — I --- ------ D Denotes storm drain pipe Denotes catch basin ` C. EN�'{Hfi�u%r t�:rs {r�--x///_9;ri�vr��l rt �E- �r�,�'�� '-'' " 's ,""`' ;' ' `='"` `s'' - — PROPOSED SEWAGE DISPOSAL SYSTEM GROUND WATER WAS ENCOUNTERED AT A GROUND WATER WAS ENCOUNTERED AT A --- DEPTH OF_ (ELEVATION ) DEPTH OF (ELEVATION ) I E - " �- 7 DEEP TEST PIT 3 (SURFACE ELEVATION ) DEEP TEST PIT 4 (SURFACE ELEVATION—) DEEP TEST PIT 5(sURFACE ELEVATION_— ) ? �` — -- -- — e` eo DATE OF TEST DATE OF TEST DATE OF TEST ' a //VfG�t4'/-its �/C�i�' �F•f���'f�/�1/r.�r' �C� Cyr 7/GIt/ �, ' 9 //YS T,+y�.' .,''7�rr�,',�c'c°-S' 8k'�Ur,./!T U.n TD f't/'�/V G N Lit G/�JSpG.�-- fOR _ TG/'!�a �,,v/ 1C �C/� /rjG? r.,;,�tE-� ?'�,�,� ,�, v�0' �j�► �,,t����r ,�J�.,�. , (�« ,� t�x DEPTH SOIL DESCRIPTION DEPTH SOIL DESCRIPTION DEPTH SOIL DESCRIPTION APPLICANT h��E" ?�Tf7% 'i1.� �E'T 't:E' .f"�G>'`�"a' TEL. N0. ?`7/ DC��'e �fJL.f"�/L< 'S/ 7G )Qe,0^' I AI �L� A,,-,r. �G V& �� �i iE�/�/- .'9+a'1'�.�' :. .�. �� ���7�t/r/�/ J+i� - -_-_ --- _-- — --- — -- - ✓ CO i'��.��/' .��'i T f`*P1c ,o,/4'L le,- .,?JW 2 / �' 1J,.97e6 .S jO,P E'cr`�.9�.E' 'ram�,5'•l'S7{M Jrt�w i� f�,SS,'r�'�� �iY�/f f�T ;�-• y /O / 1 7 7 t�e f:" C .r� '�-'/k DATE / 9 E ._ SCALE AS NOTED ,�i,��. ,� ✓�?1 G.�«p► •.» .� Ci���f�.�.�.1•...+•.y C` 7`L-`� •�/ ls�.lr'G'�'/�iSGr' TiP�'`/� �l'/�/,� /`/C/!.>J,r�`l�'if.? 7L^r��`C /D,J - <t/i'��F`k\qs,��, "I�J�iArS* ' �/.1f,+d,' i� -d +�J=✓ �. �7 .�r�✓0+xi►yV GF C : �,�' 1 O*v'lie \�Cf 9 74 .ez?T" 4/. D�L�.4 G c. ,C' -► air ' ' , ' ;.#/.s TTZ" /' 8! /iV i y M,4 "`� /i N i'1 7 1. � _W�.Al �. 4F :/'J �f G0`?'.�/0/�L ��k� /�.�` ��`� ��"� .� �t rj r0 6 DEAN � t aonn�, u2 ✓ O f.r� r. r Ma a: /V�•ri+!' /�'''r i ,j,«/ , � ��,x,� i LHOfItL C,; DESIGNED BY: DRAWN BY: CHECKED BY: 1"Z24, ,-� i9 :?� G',rF A1:f `-'L u � /+•k�• , C'F��C D. Na a65 C o- y `o- 3' �*.f�.vh'r. r� �".��^ �,!�1 ,ter k�;� :�►,��'' W - , ? ;? :'�. \ � -1— SCHOFIELO BROTHERS, INC., PROFESSIONAL CIVIL ENGINEERS _ GROUND WATER WAS ENCOUNTERED AT A — GROUND WATER WAS ENCOUNTERED AT A m � �..�,- CE•/a!�L��A�L^ �"'.,!� :r<�e3'i�2//�; 7 7, GROUND WATER WAS ENCOUNTERED AT ADEPTH OF (ELEVATION _ ) DEPTH OF (ELEVATION _ ) DEPTH OF----- (ELEVATION ) -"•' �"'�'�'� - C� JOB NO. ---