HomeMy WebLinkAboutMAYFLOWER BAKERY - FOOD Mayflower Bakery3l -
187 Falmouth Rd, HY
FORMERLY: WANGEILOS
pf Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
DAMNS ABLE, F.P.(Thomas)Lee,.
� x Daniel Luczkow,M.D. Alt.
°$ 1651® 200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 273 Issue Date: 01/01/2022
DBA: MAYFLOUR BAKERY & CAFE
OWNER: TATIANA NOBRE
Location of Establishment: 181-187 FALMOUTH ROAD HYANNIS„ MA 02601
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 48 OutdoorSeating: 0 Total Seating: 48
FEES
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2®22
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: C�iA
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
Awo
For Office Us Initial : `l
Town of Barnstable t
Q" Date Paid 1 I� �Amt Pd$L
Inspectional Services
9�°•MASS, eff
*639. `f Public Health Division Check# 23
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 IO2 10g l C21 NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: Q F/� UJf_ E 12 eAqfE
ADDRESS OF FOOD ESTABLISHMENT: IgI F- J yvn of Z. " n i$ M c� 02601
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):.
E-MAIL ADDRESS: Mck j Ao U r rn Pe 0 CI fa i a co y-y1
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: �!0�
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES NO V ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: V SEASONAL: DATES OF OPERATION: ! / TO l 1
NUMBER OF SEATS: INSIDE: 418 OUTSIDE: (0 TOTAL: 41 Y
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?
1S AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? 00
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) 0
*** SEASONAL,MOBILE& NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application Fonns\FOODAPP 2020.doc
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OWNER INFORMATION:
FULL NAME OF APPLICANT
I I _ .
SOLE OWNER: YES/NO D.O.B O3 a2� /6 OWNER PHONE# t 1 - (
ADDRESS j_ 1'A) .�/� AS .-tiA o G I 0,,2- 6 3
CORPORATE OWNER:
CORPORATE ADDRESS:
PERSON IV CH 111 LY OPERATIONTAWS:
(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
: ctvnc, 12 iO �.?o?� l:S �2. v G`� a1� `gin IL ��
ca'l
SIGNATU F 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.townolbarnstable.us/bealthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q\Application FonnsTOODAPP REV3-2019.doc
v ✓ t Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BAWN '.guts :I Paul J.Canniff,D.M.D.
MASIM 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: 273 Issue Date: ' 01/01/2021
DBA: MAYFLOUR 'BAKERY & CAFE
OWNER: TATIANA NOBRE
Location of Establishment: 181-187 FALMOUTH ROAD HYANNIS„ MA 02601
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 48 OutdoorSeating: 0 Total Seating: 48
FEES
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2®21
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM:
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
in
V
For Office Use Only: Initials:
Town of Barnstable
Date Paid 26 Amt Pd$
,A WABL , 's Inspectional Services
`� Public Health Division Check# 1� -1
Thomas McKean,Director
200 Main Street,Hyannis,JM A 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL X n�
NAME OF FOOD ESTABLISHMENT: M A Y rLo l IJ-C g �— �e ), o /.�l jp emsA �(
ADDRESS OF FOOD ESTABLISHMENT: I'9 1 FALFio c? W
1 ) �c� /A Q N l S 01 it 0
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: H(n V Ftck) 6G <tXA La I ® G t-1 'y - Coo
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: b -1-4-7 5
TOTAL NUMBER OF BATHROOMS: Z
WELL WATER:YES NO_C ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL:_ SEASONAL: DATES OF OPERATION:_/_/ TO / !
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: 2
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
CONTIYENTAL 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\Applicalion FonnsTOODAPP2020.doc
OWNER INFORMATION:
FULL NAME OF APPLICANT— �t► �T�
SOLE OWNER:�/Y>�S//NO q D.O.B O3 25 6 OWNER PHONE# 6 0 -
ADDRESS_ / e A?K) L( SAjA5 9,D e�fAj(EP-V 1 l C,C 026 3Z
CORPORATE OWNER:
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS:
List(2)Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. F
**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.�"� k]C�O Aj f'1 g-5(tS / 17o a� 1'44
2. �uD Goo-tc5 n / � l 202 y 2) 6Mt. Cm Ma�hn.S l 43b1
b1� 01 toy 1,o1ZIL
SIGNA OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile bucks 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 thcTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/ai)plications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q\Application FonnsTOODAPP REV3-2019.doe
R
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qIR Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
DAMSrkeM Paul J.Canniff,D.M.D.
i H MA 02601 F.P. Thomas Lee Alternate
� 200 Main Street, Hyannis,
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: 273 Issue Date: 12/10/2019
DBA: MAYFLOUR BAKERY & CAFE
OWNER: TATIANA NOBRE
Location of Establishment: 181-187 FALMOUTH ROAD HYANNIS, MA 02601
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 48 OutdoorSeating: 0 Total Seating: 48
FEES
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
�10'D. /R-W �
P
as & � �fquc
PIKE Foy Initials:
Town of Barnstable t2 3b(R 3.5�
Date Paid Amt Pd$
BAMSTABLE, : Inspectional Services �.��
�.
ECMo � Public Health Division Check#
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE O 11 NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: M A�A IFL,o W.KA 3 `, l_
ADDRESS OF FOOD ESTABLISHMENT: s FGA"oo �U � S a 2,6 (t
t-
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: H A-,y ELoj --0,A-acjf- () G--f-,.r/t�,-,l co LXj
TELEPHONE NUMBER OF FOOD ESTABLLISHMENT: 1�O - ✓c
TOTAL NUMBER OF BATHROOMS: UL
WELL WATER: YES NO V ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION:_/ /_ TO
NUMBER OF SEATS: INSIDE: -f OUTSIDE: TOTAL: 0
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
�k t!11
L�
OWNER INFORMATION: /� Q
FULL NAME OF APPLICANT 1 A-n A IQ � �
SOLE OWNER: YES/NO D.O.B Q� Z 5 OW—NE_R PHONE # 6 1 1- �j j -S _I Z
ADDRESS 1 6 (^ay)" 1
CORPORATE OWNER:
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS:1 1 I " -cc)F)
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
May A2��6
LA
SIG 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 1 st to Dec.3I't 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
:i
Town of Barnstable BOARD OF HEALTH
4 Paul J Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
�r BA7RNSTABLE:. �!_. John T. Norman
� S 'F 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: 273 Issue Date: 07/02/2019
DBA: MAYFLOWER BAKERY
OWNER: MARCIO MATOSO
Location of Establishment: 181-187 FALMOUTH ROAD HYANNIS, MA 02601
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 48 OutdoorSeating: 0 Total Seating: 48
FEES (�
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B- FULL BREAKFAST: '
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE- ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean,!RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
INE Tp�y For Office Use Only: Initials:
o� Town of Barnstable
Date Paid _ Amt Pd$ I�
+ &UtNSrABLE, ' Inspectional Services a-etso/>.S�
'6 q. �0 k
9�'AlED MA'�p � Public Health Division Check# A�i. ��
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601 I
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE •26 6�� NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: d�M i Pd l"r 40 Up 6 4- N N�Y 0 C&�4'
ADDRESS OF FOOD ESTABLISHMENT: { r!'- �# FA6moLj ¢i R�
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 80 C AP'Wiy T)AIA M)( C rj Ce-Tj o(!Ja'LZe_ 01/f- 0�0'0v'
a e
E-MAIL ADDRESS: 111�C�O.w n & go t�'1�/49Lo Co61
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: S( A - 0�I R
TOTAL NUMBER OF BATHROOMS: OZ
WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: _ SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: OUTSIDE: �K TOTAL: g
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)
TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL, MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
Q:W.pplication FoansTOODAPPREV2018.doc
I G�
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT D)Af4O
SOLE OWNER: YES/NO D.O.B 75 OWNER PHONE# 503-36 7 _O I W
ADDRESS_U�1 �ti OlJ(��(lfir�r�L YAAMOV41 Potf_
CORPORATE OWNER: - FEDERAL ID NO. : 1
CORPORATE ADDRESS:
ell
PERSON IN CHARGE OF DAILY OPERATIONS: ) Chi
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 m Ccj14 162 1: (Y m(� o (VIP9056
i
/2. S: '9Z A:&JE-S
.25 / oZQ)OJ
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments, including mobile trucks must be inspected by the Health Dv.
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.
I
I
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/ai)plications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a food establishment is prohibited.
TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1st to Dec. 3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FormsTOODAPPREV2018.doc
°FINE, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: �� Page: , of
° OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
BARNSTABLE. ` MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
"'A9' �' HYANNIS, MA 02601
�p .a3q.a e 508-862�644
lFOMo+ FOOD ESTABLISHMENT INSPECTION REPORT
:,-�
Name G Date3 T e of f Inspection
n Routi
Address �- Risk .-inspection
'Level Retail Previous Inspection
Telephone Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP /N Temporary Suspect Illness
Caterer General Complaint
Person i e(PIC ` Time Bed&Breakfast HACCP
) Q In: Other
Inspector Out:
r
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. o
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ p �
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ >W 'Y\
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 IL
�~
❑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) i
❑ 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 ConsumerAdvisories Lit
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations rn
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
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g Emergency Closure ❑ Voluntary Disposal ❑ Other.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or'more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 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 (FC4)(590.005) cited in this report may result in suspension or revocation of the food if no'critical violations observed,4 to 6Ion-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 i cal violations.
. f critical " water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous Toxic Materials (FC-7)(590.008 be in writing and submitted to the Board of Health at the above address violations observed,7 to non-critical violations. If 1 critical refrigeration...
) l violations=C. .
29.Special. quirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: (32C7
t
31.Dum 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 PIC's Signature Print:.(
Self Service Wait Service Provided Grease Trap Size. Variance Letter Posted Y N ` �. `'' (/ a 5Az
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
2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
r
590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F
7-102.11 Common Name-Working Containers *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
7-201.11 Separation-Storage*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*
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*
Contamination from the Consumer 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and R of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated
ated o or r Contaminated
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004 A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
( P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Tem erasures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg cri,c utnom
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 D Violations of Section 590.009 A D m cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( )-( ) ( )-( )
Ratites-165°F 15 sec*
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding 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 * (Blue Items 23-30)
3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne
12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts*
3-101.11 ' Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F .
* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient. 24. Food and Food Protection FC-3 .004
3 402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
* 5-205AI Accessibility,Operation and Maintenance
3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 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 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 500.000.
QptMET TOWN OF BARNSTABLE _ HEALTH wSPECTOR,s Establishment Name:�� Ovc_ ate: ) )3) Page: . of
OFFICE HOURS ,y,i'
B,R'�eLEoi PUBLIC
2 0 MAN SH EEVTSION 3: - :3 .M.
:300-4:30 P.M.P Item Code/ C'-,Critical Item/ DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
P HYANNIS, MA 02601 M- -FRi.
S088 62-4644 No Reference, R-Red Item PLEASE PRINT CLEARLY
�p •as9•p.�'
'FDN1A+ FOOD ESTABLISHMENT INSPECTI N REPORT _
Name V�-� Date)el a of Type of Inspection
ion I 1Z u m-
Address l - Risk 4 Food i Re-inspection
v Level Retail Previous Inspection
Telephone Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Sus ect Illness
Caterer enera ompla
Person in Gkaqe(PIC) Ln Time Bed&Breakfast Other
ACC
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 s�'a
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities -• �
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS C13�1•
❑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) j
❑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 f(�
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY Ltm
1 1 1 L -
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories 1 t
Violations Related to Good Retail Practices(Blue Itemsl Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No s
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,t e 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.
B=One critical violation and less than 4non-critical violations re 9
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 o 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 i non-critical. . If 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 a non-critical violations. If 1 critical refrigeration.
) within 10 days of receipt of this order. violation,4 to 8non-critical violations=C.
29.Special R uirements (590.009) ..
31. er
Dumps r screened from public view DATE OF RE-INSPECTION: Inspe 's i r � L6
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: 111A 1)
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N r to (�V
Dumpster Screen? Y N 'V v l v YY
. - U r -."` ._.^ -mil r:,:.rs.-.--..i r-.� 4;�...:.,,,,.r.r'�'=..e'-.f ��+r.♦.' 's- �--ir:`..f- .. :T-'� v.r.- ' lr. --..'J .v^'��._ � _
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION. PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 79 PHF Hot and Cold Holding
Contamination from Raw Ingredients 15 590.004(F)
Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45 F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
7-]02.11 Common Name-Working Containers
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130`F*
Storage*
-
Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control '
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
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*590.003(E) Removal of Exclusions and Restricti Disposition of Adulterated or 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rated or of Food*Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
ons
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
( ) P 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(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*
4-601.11(A) Clean Eggs Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ell cane 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 Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155' 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf
aces of Equipment* F
Shellfish* 3-40Li1(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( )A -(D Stuffing Containing Fish,Meat,Poultry or 590.009 Violations Si 590.009 in cater-
) Vioons o Section (A)-�)
Ratites-165°F 15 sec*
Sources* 70 Proper,Adequate Handwashing ing,mobile food,temporary and residential
y
Game and Wild Mushrooms Approved B 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under
Regulatory Authority _ 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
5 Receiving/Condition g� g g 3-403.11(A)&(D) PHFs 165'F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercially Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Y
12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 18 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70`F
* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41'F/45'F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction*Creation
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 29. 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.
Date:
°p THE r° TOWN OF BARNSTABLE HEALTH INSPEcroRs�`'fstablishment Name: 1U7� //13
Page: of
q OFFICE HOURS
PUBLIC HEALTH DIVISION - 8:00-9:30 A.M.
% BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code FR
Critical Item'- DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS, MA 02601 MON.-FRI. No Reference Red Item PLEASE PRINT CLEARLY
�A .a3v p.0'fON1P' FOOD ESTABLISHMENT INSPECTION REPORT 508-862-4644
Name Date Tyne of Type of Inspection
O eration s Routine
Address Risk d Servi Re-inspection
Level Retail Previous Inspection
Telephone Residential Kitchen Date:
Mobile o era ion
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other j lt''1 cp-
Inspector Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Q
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ 1`
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 `7a ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMElrEMPERATURE 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(HS )
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY w tft
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories 1
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. P ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspectio day,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.0001E era] 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 4npn-critical violations 9
(FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009)
within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C.
30.Other DATE OF RE-INSPECTION: pec I tur
31.Dumpster screened from public view7
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 Accoding 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 H6&s*
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°
15 Poisonous or Toxic Substances 17
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140'F*
2 590.003(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 -201.11 Se 3-501.16(A) Roasts Held At or Above 130'F*
7 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
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 Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145`F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate
Equipment*
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective mrzoor
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
aces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stu Ratites-165°F 15 sec*Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
* 12 Prevention of Contamination from Hands 3-403.11E Remaining Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated ( ) g Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140'F to 70°F
* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
3402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41'F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 1 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials I FC-7 1.008
Hand Drying Provision 29. Special Requirements
HACCP Plans F6-30112 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
n�
J .-
APPETIZER BREAKFAST
Chicken Tender Buttermilk Pancake
Mozzarella Stick Good Morning America:Egg, Bacon
Buffalo Chicken and Cheese on a Grilled French
Filet Mignon with Fries Bread.
Picanha with Yuca Happy Morning:Sausage, Egg, Bacon
and cheese on a Grilled French
Bread.
SALADAS Sunshine Day:3 Pancakes, Bacon, 2
Caesar Salad: Romaine Lettuce with Eggs, Ham and Cheese on a Grilled
Parmesan Cheese, tossed with French Bread.
Croutons and served with Caesar Sunrise: Ham, Cheese and Tomato on
a Grilled French Breach.
dressing.
Greek Salad: Romaine Lettuce, Feta
Cheese, Black Olives, Cucumbers,
Onions, Peppers and Tomato.
Mayflower Salad: Romaine Lettuce,
Bacon, Cucumbers, Onions,Tomato
and Carrots with Italian Dressing.
SOUP
Soup of the Day
DESSERT —`7 t- �s ,�a�OH _ V'0 �I C:VW-Q ;, C-Kkc� -eke.
Pastries , C cS, 0 0 K i eS , p ieS lx r'1S , C P C ��`� , flit Ctck t 0
J
Grilled Sandwiches
All Sandwiches are served on Mayflower SANDWICHES
French Bread. All Sandwiches are served on Mayflower
Served with Choice of Chips or French Fries. Bread
Arrrerdcano:Ham and Cheese
South Brasil: PJcanha, Caramelized
ltallano:Salami, Ham, Mortadella,
Onions, Lettuce and Tomato.
Tender.Filet Mignon, Bacon, Choice
Bacon and Olive Oil.
Tuna Salad:Mayflower Tuna Salad,
of Cheese, Lettuce and Tomato. Choice of Cheese, Lettuce and
Pampas: Roasted Ribs, Grilled Tomato.
Onions, Tomato with a BB Q Sauce B.LT.: Bacon, Lettuce and Tomato
Hot Dog
Grilled Chicken Sandwiches
All Sandwiches are served on Mayflower ! BURGERS
Bread. `
Served with Choice of Chips or French Fries. All Burgers are served on Mayflower Bun.
Served with Choice of Chips or French Fries.
Griped Chicken: Grilled Chicken Add Bacon to any Burger$2.00
Breast, Cheddar Cheese, Lettuce, Cheeseburger: Choice of Cheese,
Tomato and Mayo. Lettuce,Tomato and Mayo.
Grilled Chicken Bacon Melt:Grilled Cape Cod Cheeseburger: Fresh Grilled
Chicken Breast, Bacon, Choice of Mushrooms, Grilled Onions, Bacon,
Cheese, Lettuce, Tomato and Mayo. Choice of Cheese, Lettuce,Tomato
Hot Chicken; Grilled Chicken Breast, and Mayo.
Pepper Jack Cheese, Lettuce, Tomato Mayflower8urger: Bacon, Egg,
and Mayo. Choice of Cheese, Frank, Ham,
South of the Border: Grilled Chicken Lettuce, Tomato, Corn and Mayo.
Breast, Swiss Cheese, Bacon, Grilled
Onions, Grilled Mushrooms and
Mayo.
R.00 R.00
MPS-250 SS
NIPS-350 SS
MPS-500 SS CS-500 SS
Etiqueta do produto
GPANIZ IND. DE EQUIP. P/ALIM. LTDA Ftin.uo_ta_-d�nrndiitn-.
■ ■ Adolf l,anclazzo.2010-Vila Maestra GPANIZ IND. DE EQUIP. P/ALIM. LTD
cNPJ:90 771 833/0001-49 CEP:95046-800 i ■ Aclolfo Randazzo.2010-Vila M aesoa
c'axias do Sul.RS-Brasil CNPJ:90 771 83310001-49 CEP:95046-800
Fone:54 21013400 www.gpaniz.com.bi Caxi is clo Sul.RS-Brasil
Fone:54 21013400 www.gpaniz.corn.bi
P1011HIR11101W1 1One]
11 019 fforej
(24948) - C/PED MONO (29980) - INOX - MONO
INTV 60Hz 3P ME ING BR 220V 60Hz ME ING
Tensao: Frequencia: Potencia:
.T
127V 60HZ 60OW ensao: Frequencia: Potencia:
Nr° Ordem: b0841
aixa: Grau de Prot.: Peso Liq.: PesoBru.: 220V 60HZ 3300W
809GG77 11 PX1 85,00k 109,00kg Nr° Ordd+e�+m: Caixa: Grau de iProt.: Peso Liq.: Peso Bru.:
Data de Liberacao: Nr° do Reg. Empresa: Periodo Lig./Desl.: 8096605 72O6S I PX I 200,00k 240f00k
01/03/2019 CRER RS 115382 min Data de Liberacao: Nr° do Reg. Empresa: Periodo Lig./Desl.:
1:u2,2013 IO 30:�.�,; r1S619000020
/ /2019 CRER RS115392 min
Nr° Serie: e:
1010319000029
0
III IIIIIIIIIIIIIIIIIIIIIII II III
01/03i2015 10:27:1
lit
ATENDIMENTO AO CONSUMIDOR L.
(O-XX-54) 2101 3400 ,66(f?,
1 ATENDIMENTO AO CONSUMIDOR
0800-704-2366 i (O-XX-54) 2101 3400
www.gpaniz.com.br gpaniz@gpaniz.00m.br
1 0800-704-2366
G.Paniz Ind0stria de Equipamentos pare Alimentagao Ltda. www.gpaniz.com.br gpaniz@gpaniz.com.br
Adolfo Randazzo,2010- CEP.95046-800-Caxias do Sul-RS G.Paniz Ind6stria de Equipamentos para Alimentaq io Ltda.
CNPJ 90.771.83310001-49 Adolfo Randazzo,2010- CEP.95046-800-Caxias do Sul-RS
CNPJ 90.771.833/0001-49
N
MODELADORA DE PAES
BREAD SHAPER DOUGH BREAKER
CILINDRO SOBADOR
MPS-250 SS
MPS-350 SS
MPS-500 SS CS-500
R W v'0NV eNll Sy
Manual cue Instruga0
Instruction Manual Instruction Manual
Manual de instrucciones
Town of Barnstable
oFjri�r Building Department Services
Brian Florence CBO
g BARNSTABI,E
Building Commissioner
• iA MASS.LE, ►
q$a ;699 ,�� 200 Main Street, Hyannis,MA 02601 9n DLcn S ILLE mnnrkW
.9:Vf 151l.IL•491JlAllF•Nt!i d:iYfVS:t
15794014
rFD MA'S a www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
April 12,2019
Mr. Jose L. Dias
Mr. Marcio G. Matoso
c/o Mr. Rene Poyant, Manager
Poyant Real Estate
20F Camp Opechee Road
Centerville,MA 02632
RE: Site Plan Review#028-19 Mayflower Bakery Cafe
185 & 187 Falmouth Road,Hyannis Map 311, Parcel 080
Proposal: Bakery/Caf6 with 48 seats in 3,000 s.f.tenant space previously occupied by
D'Angelos. No alcohol or outdoor seating is proposed.
Dear Mr. Dias and Mr. Matoso:
The above proposal was administratively approved by the Site Plan Review Committee at the
informal site plan review meeting held April 9, 2019 subject to the following:
• At the building permit stage, consultation with Deputy Chief Dean Melanson is
recommended for required updates for key box location and FD access. Contact:
Deputy Chief Dean Melanson,Hyannis FD 508-775-1300.
• Hood fire suppression system requires inspection every 6 months per Hyannis FD.
• A floor plan is required to be submitted to the Health Department for approval and an
updated plan will need approval if changes are proposed. A Food Service Permit is
required from the Board of Health, Contact: Health Dept. 508-862-4644 for application
assistance. ,
• A Common Victualler License as well as a Non-Live Entertainment License,for
televisions is required fi•om the Licensing Authority. Contact Maggie Flynn, Licensing
Assistant 508-862-4774 for application assistance.
o Scales will need to be inspected and sealed prior to opening and annually thereafter.
Contact Kim. Cavanaugh, Weights &Measures 508-862-4771 to schedule an
appointment.
o The 1,000 gallon exterior grease trap was confirmed to be adequate. Regular pumping
will be required as maintenance. Contact: Griffin Beaudoin, Interim Assistant Town
Engineer 508-790-6400.
Applicant must obtain all other applicable permits, licenses and approvals required.
Sincerely,
Ellen M. Swiniarski
Site Plan Review Coordinator
CC: Brian Florence,Building Commissioner, SPR Chairman
Hyannis FD
Licensing
Health Department
DPW
Weights and Measures
Bellaire, Dianna
From: Swiniarski, Ellen
Sent: Wednesday,June 12, 2019 9:30 AM
To: Bellaire, Dianna
Subject: FW: Mayflower Bakery Cafe
Attachments: Mayflower Bakery Cafe SPR Letter.pdf
Hi Dianna,
Attached is the SPR letter for Mayflower. Contact Info for the two applicants: Jose Dias 508-367-6111 & Marcio G.
Matoso 508-364-0780 *2675
Thanks, Ellen
Ellen Swiniarski
Site Plan. Re'vieiv Coordinator~
Tinvn. of-Dar-astable
5o8-862-4679
From: Swiniarski, Ellen
Sent: Tuesday, April 16, 2019 1:38 PM
To: 'Poyant Realty'
Cc: Florence, Brian; Lauzon, Jeffrey; Melanson, Dean; Flynn, Margaret; Stanton, David; McKean, Thomas; Beaudoin,
Griffin (Philip); Cavanaugh, Kimberly; Scali, Richard
Subject: Mayflower Bakery Cafe
Dear Rene,
Attached is the site plan review approval letter from meeting with staff on April 9. Please pass along this letter to Mr.
Dias & Mr. Matoso with staff's best wishes for a successful business. Please do not hesitate to call if you need
assistance.
Best,
Ellen S.
Ellen Swiniarski
Site Plan 1Zeview Coordinator
To-wn of Barnstable
5o8-862-4679
1
Applic tion\Plan review Fee: $ Permit Fee$ (see staff for fees)
Nam lof Business: M E� Ciq E DATE
Pin
zss: 1 .� b! S _ G 1ye A10 all?
Own ir:
h;Se ts- Indoors: _ Outdoors*:� (If seating provided, see Licensing department)
�f o aside dining provided,you must fill out and submit application for outside dining/sidewalk cafe
RESTAURANTS
Yes No
Floor plans submitted.
Staff meeting review date: APOL 9 W/9
Food establishment application form filled out and submitted
Cut\S ec equipment sheets submitted for all food equipment)
X
Adequate septic system or town sewer
In-ground grease trap or GRD with a variance
Menu submitted
- Allergy notice present - \/
- Consumer advisory.present for undercooked foods on menu (if required)
Water supply-Approved source. If well annual testing& licensed operator
Handwash sinks—location, number, design and signs
Touchless faucets (see policy) Z
Three compartment'sink with drain boards �C
Area to air dry all washed equipment, utensils, dishes, etc. K
Dishwasher provided
If low temperature:
-Low sanitizer alarm (for new dishwashers)
- Type of sanitizer—Quats,bleach or other (specify if other)
- Sanitizer log book
*If no dishwasher provided, see policy
Sanitizer test strips (for-dishwasher, 3 bay sirnk, wiping cloth sanitizer buckets, etc.)
Prep Sink- See policy
Mop Sink—Mops to be hung properly to air dry
Frozen Dessert Machine (Dairy)
Hood Ventilation System
Number of Bathrooms Proposed:
1. Touchless Faucet (see policy) IJ
2. Ventilation Systems✓V
3. Self-closing doors
4. Soap Dispensers—Mow-ited
5. Paper Towels—Mounted
6. Handwashing Signs V
7. Women's Room—Covered trash bin and\or sanitary napkin receptacle
Floors, Walls, Ceilings (Smooth, washable, easily cleanable surfaces)
FINISH SCHEDULE [SEE ADDENDUM ATTACHED]
Lighting—Sufficient/lighting shielded or shatterproof
Refuse containers covered (sufficient number and size, durable easily cleaned, insect &
rodent resistant)
- Dumpster impervious ground and blocked from public view(i.e. fencing\evergreens)
Dry storage room location shown on floor plan
Employees personal storage (i.e. coats, bags, etc) area designated. May use lockers
Poisonous or Toxic Materials (storage located marked on plan, labeled containers)
Screens for Windows and Doors
-Any questions, please contact the Health Inspector for your area
-Plan approval shall be granted or denied within 30 days after Staff meeting review
-This list is not inclusive of all Federal, State and Local requirements
Revised 04/25/2017
Q:restaurantAnew restaurant checklistdoc
�■ BftRdhLg Bepaftaeat
} Brian.Florence, CB
■ Building Commissioner.
ZOD Main Street,Hyannis,MA 02601 C�zgt
� �� v✓Vryr toWA f7a�stable
--------------------
P-re~application for)Ta i ess Certf,cate
I 67.0
a Parse
Data � � U � P 1 .
Applicant Information
ff\Ay r(.Q�J.��, i� 14�y _ CA r_e l L Ce
Ap Plicants Nam,-
. Applicants Addrens. O C A.P TA i/J .M -CC-;J t„1 led;W M4 : CJ
Email Addtass MAkC�0—fn A 0-5 0 po-rm g i.L. co/y
TclephonoNumber J�U�- I Lis{ed[� UnlisEcd El
Business Information
New�usiness7 -----------------------------------------GD No
Business is aregiaterodcorporetion9 ------------------------. ycs No
rf yes Name of Corporation
Does business opuafs imdcr the registered corporate na 0 Yes No
Is the.businese a solepraprietor4 or home ocoupaiioO --------- Yes No
If yes then.a Rome O�c/cupadon Rcgishation is required—See Building Division Staff.
Name of Business Co r_P_ t L C
Busincse Address 8 Jc " �' C �'1Gt/
Typo OMMiness
Biff—di1 ' g Co Mmssioner Of oo Me Only
Conditions —'
bY1
B12diag Commission 8� Date
Clerk Off.ce Use Only
_ I
_
kc
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,iMASSACHUSETTS
ZIppYication for -Migpoml *pgtem Construction i3ermit
Application for a Permit to Construct( )Repair(--I Upgrade( )Abandon( ) El Complete System [;?Vil vidual Components
Locatio Address or Lot No. 187 —A hq t 0 oA "OeC, Owner's Name,Addres d Tel No. r
se so%sgff/��l
�p��Z d$) pox,,
/ �0. C S � 'L
a U°�g
Installer's Name,Address,and.4el$N jj CANCC Designer's Name,Address and Tel.No.
350 Main Street
W. Yarmouth,
Type of Building:
Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /0 a a Type of S.A.S. le el- ',r
Description of Soil /
Nature of Repairs or Alterations(Answer when applicable) /2 f' « i Sf n H D Idn,,
4R(%c 7Lo4sik t,J/ f{•020 !F,4/ clear4,2 ¢." H-16 JA,01< cd1(AS',oect7
A r bet a"i c tJ c_
U.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
I' Signed/ '' Date rT- /0 -jo°
Application Approved by Date
Application Disapproved f r the following reasons
Permit No.7 e-� Date Issued
-R X
_ 7
-R.
C AQ, .
Fee S
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
» Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for Xi5ponl *p5tem Construction Vermit x.
Application for a Permit to Construct( )Repair(✓f Upgrade( )Abandon( ) ❑Complete System [;�<dividual Components
Location Address or Lot No. /&7 i A/i,, \� , , Owner's Name,Address.qnd Tel No. �^
p J0��1vit l rG I
s o 's a cel
77) - UU79
Installer's Name,Address,and J%I&S CANCO Designer's Name,Address and Tel.No.
350 Main Street '
W. Yarmouth, MA 0267�
Type bf Building:
Dwelling No.of Bedrooms U Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title \
Size of Septic Tank /0 o v Type of S.A.S. q 1, r.� t- �e Sri r
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1?e4!41 z e ,e x S f•n g /f y /o a 5A-1, ;
.Tell fo�.�(, tnJl f( ,1v /uo o H /y V/9.0tc CG164EdPcP
�S/�:aFhcaS ¢ ��urL
Date last inspected: t'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved f r the followin reasons
Permit No. .^ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( ✓)Upgraded( )
Abandoned( )by C� U
at G 7 1� ' zr rv( ,i , �/A219 en constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.T "�OWk9 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date _ 1 !H Cl Inspector
No. d
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
M0001 *pgtem Construction Vermit
Permission is hereby granted to Construct( )Repair( ✓f Upgrade( -Abandon( )
System located at /�/ 6
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
� L
Provided:Construction mu it be �O �F_-
11let within three years of the date ofi�PRI/fiA
Date: Approved by _ ,# f ? � %
ASSEM IIIAR h0:
PARCEL NO... _
Fu$.....s. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
owe ............... oF....V ..r.'.h.� � .... ...........................................
Apptiration for Uiipuiia1 Workii Tnntknr#ion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (V-) an Individual Sewage Disposal
System at: n
.................... Mgw .Co +._.. s�k?h.f. ...................... ----•--•-•---•------......._........-----------------•-----......._......... ......
Location-Addres or Lot o.
S- euQ Cam.. leal. ..... 1 ga4_..Fa-►'� _.R0_mr.�, ritll ..............................
Owner Ad ress
w .. 6---ate ed..--••------- 35aF.....
Installer Address
dType of Building Size Lot............................Sq. feet
- Dwelling—No. of Bedrooms....................._......................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons........_.__._.............. Showers ( ) — Cafeteria ( )
a Design Flow-----------------------------•-•-•------•-gallons --er person per day. Total daily
flow----•-......-----------........ •-gallons.
Other fixtures ................. .... . .
W g g P P P Y Y ----•---•-----------•-------------------gallons.
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.------.................
------------------------------------------•---....----............._.........--•-•-•----•-----••--.........................................................
0 Description of Soil........................................................................................................................................................................
x
U ---------------
•---------------------------------
•-------------------------------
•-----------
•--------------------------------------
•----------------------------------------------------------
-........
-------------------------------------------------------------------------------------------------------------- --------- -------- _
Nature of Repairs or Alterations—Answ r when a licable.__&-_06W rq�N1LQU 1't�5r _.C. _
kw..... —0ri--- -- - ----- - ' -------------------------------------------------------------------------------------------------------------------------
Agreement: �!
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iT jE 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 the board of health.
Signed-- -- ----- ---------- ............................. ......�1- 'roh ......
ate
Application Approved By.........--- . --- ---------•----------••---•---•-----------------
D
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
" BOARD(� _OF HEALTH
oWxt ......................oF...VJC�.rr°��tP�i.!?ft.............---........................................
Applirafinn for 11isposal Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (%.) an Individual Sewage Disposal
System at
1010
Location-Address p t� o Lot""'
S�c� cQ ��'�r,m #� i Fa. �cn.�rti•toc��.......�.•... _fdf.�r��nr� •-
Owner t L A dress
a f rn�r� 5G ..{C.... `a,.."r.«a.� _.•�.��s
.........................................................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons................._---------- Showers ( ) — Cafeteria ( )
C4 Other fixtures --------•----------------------------------
------..--.•--•----------------------------------
•--••------- ------------------•-•------------
W Design Flow............................................gallons per person per day. Total daily flow._.........•..................._._..__.__._.gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—'No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter................_--- Depth below inlet.................... Total leaching area............._....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
a ---••-----...--•-•...-•---••.........•••---•--••.............•-••......••• Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x
D Descr-ipti n Aoil.........................
x
U ------------------------------------------------------------------------------------------------------------------------------------=---------------------------------------------------------••-------
w
UNature of Repairs or Alterations—Ans Sr when applicable.. ? cr �._t"- _v_!p,q�¢er�.,,i..... tatix.!J.P. �-,,,_,_
pY►___..G.,G � .6.-----------•-----------•---------- -------- -•------ ----.... ......•. ••--•--• -• ....---.. ..
Agreement: V
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'='tLi: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board
//of health.
Signed "- c� oaNitf,+A.l ? q... ........
Application Approved By..... -- -----••. ........ '
Date
Application Disapproved for the following reasons:------•--------•----•-•---------------------------------------•-------------•--•--------------------•.........--
--•---•-----------------•••--••••-•--•••••••••--••-••••--•--.._............•--•-••••---•------••••-•---•--••--••-•-•-••-••••-••-•••---•--•••...........................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
e•
THE COMMONWEALTH OF MASSACHUSETTS
�Qvg4 CT�� BOARD OF HEALTH I
yGawl...................OF....`;1su..aa?1 .!,.................................................
Tntifirate of TOutplittnrr
.THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairefd,V—)
by-------------_------...0 9VN0Pj..................................................................................................................................................
Installer
at........................ ...... lw.o --- -------- g,n„�� -----•-------------------------------
has been installed in accordance with the provisions o >Ti%.h j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No—Ca. ........ dated...... _z..., 'b__________________
G�__�A
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS AANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY. �.
'DATE............................—�Y__ .......•-••---..........•---------- or....................................................................................
L THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
&...7A tY>. L......... .......gyp... C� It UjU_ ............,...._.........................._...
O . FEE._ :a-.'..-_.
►i rya 1 jark Tnntrudivit rrmit
Permission is hereby grante _••--• ----•••-- -. �•---•--•••....----•-••-••--•--•••-----•---••...._--•--•.................................
to Construct ( ) or Repair)C) an Individual Sewage Disposal System
at No
Street
---...... ..---.._. '------••---•-�r--- Dated-------------- ..
-----------•.............
ass own on the application or Disposal Works Construction P mit No � N
y Board of Health
�`��---�"�'•�-------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
PRO SED' "•SANITAR.Y... SEWEROSTEM
P + ~ I N
HYANNIS B A R N S T A B L E . MASS.
FOR
�� �E
3 JOSEPH P. . MACOMBER 8 SON INC.
SCALE : I " = 10' DATE: MARCH 23, 1976
CHARLES N.SAVERY INC. REG. C.E. L.S. 712 MAIN ST. HYANNIS, MASS
''r
LEACHING PIT /
y 12' Diom.X 10' Depth.
131of I•I/2"Stone) '
40
LEACHING PIT
' DIST. BOX -i P'Pe -- p �12'Diam.X 10'Da�� `k _
f 3'of I•I/2"Stone)N
5 El 13'
k, » SEPTIC TANK
I" 2500 Gal. Cap,
i H-20 Whee I Load
i �3'
F t
4-F s
GREASE TRAP
1000 Gal.Cap.
H-2OWheel Load I .,
al
�� aI 10 =
• 1 1 .
REAR OF BUIL DI NG
ANGELO'S SUB ���` ROSEN
OD
SHOP SHOP SHOP '
g N o 9UNIKIS w -1
/ ( 44 Seats ) no e420
/ 4 o
TE
N...0 '• � ,rt
, r 76 16
,-� 0
00&Ar er, C/,04
'No.._...3 .. ®S� FEx.l...14...94...._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T.own. ...........0 F.........Barnstable
. .. .... ...................._-._..._......_-...---.....-----------••--...----...----_....
Allp iration for Uiipnsa1 Works Tnnstrnrtiun Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at:
Plaza Twenty-Eight, Falmouth Rd., Hyannis, MA 02601
..... ....._.. --. .................... .................... -•-••----••-------•----------•-•-•----•-•-•------••-------.........--•-••-._.............._-••_..
Location-Address or Lot No.
JUi P'Ji.._.&_..Maxcal__R___2nyant__.....----•-•....................... Plaza Veenly_,Eisht...4_.Faliagut_h..Rd...,.__iyannis, 02601
Owner Address
a AA..B..Q.eas.pQ_o_1_.ae3zv1c.e................................................. 12$_.BlabLQps..Ta=aye+--lIyaamia.e-._MA.....Q26_0.....
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a 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........................................
aTest Pit No. I................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........................
----------------------------------------------------------------•---.._......._.._•-••••-•--••_..............................................................
0 Description of Soil.........Sand.....................................................................................................................................................
x
W -----------------------------------------------------------------------------------------------------------------------------------------------------------............................................
U Nature of Repairs or Alterations—Answer when applicable-install---a...15D0®a,ll.on.--sapti,c._Tan-k4920.}-1....
H2O Distribution Box and -. •• , -- _.. _-with_si ne____________•________________________________
..........................................
= a_ -
Plu �(gno, g grease trap & piping from building.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance.,Compliance.ha5 been issued by the boar of h h.
n ----------------- ------•- - --------------- F 6l 8183
` /Date
Application Approve : ..... .................................... ! l .
6 __ 8 ......
Date
Application Disapproved f t following reasons-----------------------------•---------------------------------------------------------------------._......••••--
--•--•----------------------------------- -•----------------•-----------•-----------------•------------•-----•.._---------------- -----................................................................
Date
`No....8.,3-`y Fmc.l...1Q,.Q 2......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,r
T Own Barnstable
OF..........................................................................................
Appliration for Dhipos ai 10orks Tontrurtion amit
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at:
Plaza Twenty-Eight, Falmouth Rd., Hyannis, MA 02601
...............- _.._.. --.......-- .................... ..._...___...---•-••--•------•--..............-----•••---•------•-----...................----_.._.
Location-Address or Lot No.
Julie..�._..�..�azcQ�1..R..-P.scent..................................... P.lea._'�t�exi�Y-:��.fit..�-•k'al.mctath..ad�....Hy�,nais► 02601
Owner Address
A .P... S �QQ�.. z io a---------------------------- ...MA......Q2601.....
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers —. Cafeteria
0.1 Other fixtures .....................................
d
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 ( )
'—' Percolation TeRisults••-----_m nutesPerformed
r --• • ----•-••---•••-•- ---- --- Date........................................
Test Pi No
Pe inch Depth of Test Pit._.----------------- Depth to ground water-.___.-------.----__---.
fi Test Pit No. 2................minutes per inch Depth of Test Pit........_..._._.___. Depth to ground water........................
a •••••••-••••-----------•-•--•--•••-••••--••••-••...............•--•---••--•......--•------•---•--_--........................................................
O Description of Soil.........Salnci
........
.............................................................................................................................................
x
w ...••••••-••-------•---------------•-------•----•••-•-••-•----•-••-•••-•••••-----•--•••-•-••-•---...----••-•--••••-------•--.........•-••---•••••-•-••---..............................................
U N ure of Re airs or Alterations—Answer when a licableins'�a.1.1_.,M._15OQQal3-om-•se- tic--Tank H2a
U PP • A l �r--..
H2O Dti$tributPion Box, and_. _. ,_000 gal lon.-lead_.pit._0 20)...Vith._atone..............................................
r u -
P7.u�►���.�ng grease trap & piping from building.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITM4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance- been issued by the boar of hh.
r..6 `g 83........_
D tg
Application Approve;;��. `••- �-!' •--•--•--•-••-•••••••••••-----••••-••-••-•••-•-••-•••••••• fi.. (83
* Date
Application Disapproved f t following reasons-----------------------------------------------------------------------------------------------------------••---
.........................:............... ....••••..•-••-•--•--••••-•-•-••••••--.......--••--•---•---••-•-••-•-•......._..•••••---••-•••-••••••--••-•-------•-•-••••--••----•-•-------•-•••-•-•-•--••-
_Daft li
Permit No._• $3........_.. Issued 6/ 8/83 -----
Daze
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town O F...............Barnstable
........ .....................................................
Trrtifiratr of Tautpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by...A. .P_.Cesspo of Service,...�28 Bis3�ops-_Terra�e1 HyaEllln�...AAA....Q26Q1.............•-•-----••-••••••••----• \\�
Installer
at__ Plaza Twenty EiOht, F mouth R .,_ Hyannis, 02601•-• Julie M.._&--MareWl.__Poyant_--•--
has been installed in accordance with the provisions of TITLE 5 2Whe State Sanitary Code as described in the ?'
application for Disposal Works Construction Permit Ncm_... ................... dated. _6 .$1 3.___.............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU D AS A GUARANTEE THAT THE \`
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ... 6�_. ....[-g3..._....•-••--••...................••--.. ' Inspector.... -••---•---••-•-••••--•-•-•-••---•----•••-•-•-•••-••••--•••••-•_-•_--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town........OF.............Bazr>stable
.. 5 ................................. ....Baiw.-t.abl.e.............................................
.
No.... ...•-_..�...... FEE......i0.00......
,% �i��ro��t1 ork� �on�#rtion rrntit
Permission is hereby granted...........A: & B Cesspool Service
.........................---------------...------------------•-------------------.........-•-••-••......._••••--•-•--•
to Const uct ) r RRepa (( x) n Indiv' ua�� SSewa a Dis osal S tem
wen t'—E%R Plaza, alM N Rd.., l yann3s, 099 01 — June M. & Marcel Poyaht
at.No.......• --------------------------------------•••--••••...._.........•--_-• ---- ----------------------...----------••-••-••............_-•_-
,: Street
as'shown on the application for Disposal Works Construction Permit No......8,3" ___ ated.. _.....83.........................
K183 oard of ealth
DATE. --•-----••-•----•-•--• •-•-••._....---•-••--........•-•--•...--•__•- ,<. ...
FORM 1255 A. M. SULKIN, INC., BOSTON
LOCL,T-ION ' �- .�. 5EW0,61E PERMIT UO.
VILLAGE tt�
lwsTQLLERS U&ME 4,- ADDRESS
BUILDER 'S 1J &VAF- ADDRESS
DATE PERWT ISSUED
DATE COMPLI &MCE ISSUED : — ��
II � � /
`� � A
e �
. �
i
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/ � f
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:� �, � o s
-rv� S',�/o,�
LOCKE,ION SEWAGE PERMIT NO.
, VILLAGE
INSTALLER'S NAME & ADDRESS
' F
BUILDER OR OWNER /
P�
DATE, PERMIT ISSUED
DATE COMPLIENCE ISSUED _�
_ -
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