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HomeMy WebLinkAboutSTOP & SHOP FOOD - FOOD STOP & SHOP 3900 FALMOUTH RD ~$TOKS rrN%L L.S. _ Town of Barnstable BOARD OF HEALTH 0 John T.Norman Board of Health Donald A.Gaudagnoli,M.D. rx:sce. F.P.(Thomas)Lee,. 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. ffor+�a�a 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: 757 Issue Date: 01/01/2022 DBA: SUPER STOP & SHOP #066 OWNER: STOP &SHOP SUPERMARKET CO Location of Establishment: 3900 FALMOUTH ROAD. MARSTONS MILLS„ MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2022 RETAIL FOOD: $285.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Gi FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: 0IC(Y\0At For Office Use 0mly— Initials:"'E' Town of Barnstable y� # � Date Paid Amt Pd$ BAMSPABLE, : Inspectional Services _ 7D 16;,9.a`� Check Public Health Division S Thomas McKean, Director q (5,M 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE (0 21 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: S4-0 ` 0 (� p ADDRESS OF FOOD ESTABLISHMENT: woo X �-M4,L;c cnx MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: SS .c Xo re. D U to(o . S �'e l� t.6t e GZ S 4-o p h o p , Gpm TELEPHONE NUMBER OF FOOD ESTABLISHMENT: /3 7 �( TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:�� SEASONAL: DATES OF OPERATION:O//0//,21 TO 1A NUMBER OF SEATS: INSIDE: Q OUTSIDE: O 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 REOUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? r IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? /I//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) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FonnsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT 0 ermos \4 o• L SOLE OWNER:O/NO OWNER PHONE# 7,0 z U I o Z✓ ADDRESS_/,3FJ—/ &OCZCk- cS Q\,�1 t C—!A CORPORATE OWNER: CORPORATE ADDRESS: /3 llgliwok (57' A'LiA wc=r ran• n ac cog PERSON IN CHARGE OF DAILY OPERATIONS: �je bo r h S e aA e 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 I. 1�e6rak �.1e- i 9' izo�J� 2: Cr-1 C &0Cd ha►( � � l16 / ZOZ� t o /-7 / ,7va/ 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 Healti 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 cat--rs 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.tis/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. 3 1"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 The Stop & Shop Supermarket Company LLC Officers: Title Name _ r President. Gordon Reid Treasurer Mary Lynn Phillips Secretary Jeff Dichele Assistant Secretary Maria Silvestri Mana ers: Gordon Reid Jeff Dichele Mary Lynn Phillips Robert Yager Rudolph Thomas DiPietro III Stacy Wiggins All Officers & Managers of The Stop & Shop Supermarket Company LLC have the following business address: Stop & Shop Supermarket Company 1385 Hancock Street Quincy, MA 02169 617-770-8708 ACCO o® CERTIFICATE OF LIABILITY FDATE(MM/DD'YM) TY INSURANCE 12/08/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and.conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT - Marsh USA Inc. NAME: 1717 Arch Street PHONE I FAX A/C Ext: A/C No Philadelphia,PA 19103-2797 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN101295509—GAWXW-20-21 INSURER A:ACE American Insurance Company 122667 INSURED The Stop&Shop Supermarket Company LLC INSURER B:ACE Fire Underwriters Ins.Co. 20702 Atin:Rick Shaughnessy INSURER C:Indemn4y Ins Co Of North America I43575 1385 Hancock Street Quincy,MA 02169 INSURER D:NiA N/A INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CLE-006635424-02 REVISION NUMBER: 2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTA'N, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I �ADDLISJBRI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I POLICY NUMBER MMIDOIYYY MMIDO/YWY OMITS A [X::[C7 MMERCIALGENERALLIABILITY HDOG71574349 12,101/2020 .12101/2021EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE u OCCUR ! _ DAMAGE TO RENTED 1 PREMISES(Ea occurrence) $ 2,000,000 MED EXP(Any one person) (S 5,000 I PERSONAL&ADV INJURY j$ 2,000,000 �GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY PRO- LOC ! PRODUCTS-COMP/OP AGG $ 2,000,000 iOTHER: j S A AUTOMOBILE LIABILITY. ISAH25308840 :12r01/2020 12/01I2021 COMBINED SINGLE, LIMIT II(Ea accident) $ 2,000,000 X I ANY AUTO II F 'SELF INSURED FOR PHYSICAL' BODILY INJURY(Per person) $ I��I OWNED SCHEDULED ! 'DAMAGE' AUTOS ONLY AUTOS ! BODILY INJURY(Per accident) $ ! HIRED AUTOSNON-OWNED LY I I PROPERTY-DAMAGE AUTOS ONLY AUTOS ONLY Per accident is Fi UMBRELLA LIAB OCCUR - EACH OCCURRENCE I$ —�EXCESS LIAB CLAIMS-MADE -- AGGREGATE S I DED RETENTIONS I S C WORKERS COMPENSATION I I WLRC6781244A(ADS) 12.101020 12M1/2021 PER OTH- AND EMPLOYERS'LIABILITY .STATUTE ER 8 ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N SCFC67812529(WI) ;12/01/2020 12/20/2021 , E.L.EACH ACCIDENT 1,000,000 A !OFFICER/MEMBEREXCLUE N❑I N/A I$ I(Mandatory in NH) WLRC67812566(TN) 12i01020 12/01i2021 E.L.DISEASE-EA EMPLOYEE$ 1,000,000 R yes,describe under 1,000,000 !DES OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT i S A EXCESS WORKERS COMPENSATION WCUC67812487 112!01/2020 12;01;2021 I 1,000,000 I I l DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACOF:D 101.Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION The Stop and Shop Supermarket Company SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn:Rick Shaughnessy ACCORDANCE WITH THE POLICY PROVISIONS. 1385 Hancock Street Quincy,MA 02169 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee �taLupo� \ u ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.rruiss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: The Stop &Shop Supermarket Company LLC Address: 1385 Hancock St City/State/Zip: Quincy MA 02169 Phone#: 800-288-8415 Are you an employer?Check the appropriate box: Business Type(required): 1.® I am a employer with employees(full and/ 5. ®Retail orpait-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto,etc.) I employees working for me in any capacity. g ❑Non-profit rofit [No workers comp.insurance required] 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp.insurance required]* 4.El We are a non-profit organization,staffed by volunteers, 11 ❑Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#i. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Ahold Delhaize America Holding, Inc. and its subsidiaries Insurer's Address: 1385 Hancock St City/State/Zip: Quincy MA 02169 Policy#or Self-ins.Lic.# 576 Expiration Date: 8/1/2022 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify, der thepains andpenalties ofperjury that the information provided above is true and correct Si afore: Date: 9/7/2021 Phone#: 617.689.4921 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town. Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#: ,.vww.mass.-,o% dia i t f e; BOARD OF HEALTH Town of Barnstable John T.Norman Board of Health Donald A.Gaudagnoli,M.D. Y' B"NSeABMI I ' 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, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 757 Issue Date: 01/01/2021 DBA: SUPER STOP & SHOP #066 OWNER: STOP &SHOP SUPERMARKET CO Location of Establishment: 3900 FALMOUTH ROAD. MARSTONS MILLS„ MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021 RETAIL FOOD: $285.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q/ FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: F1HE r Initials: �•° °�ti� Town of Barnstable Date Paid I 2 Amt Pd$ Y BARNWABLE, t Inspectional Services prfD MAY n 1639. Public Health Division Chec24 k 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 loZ ;J''11() NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: O �1- �✓Yl D D At-0 Lte:, ADDRESS OF FOOD ESTABLISHMENT: ,3 qOU Pa-]✓ ' 0W4-k-N l�U� �Y'�7"� A i 1 1`S MAILING ADDRESS(IF DIFFERENT FROM ABOVE): LbCQV:5j i'1A 13�,� Na�co�(C cS� Qv.�Vic, V1l�l E-MAIL ADDRESS: J Lis o-n. Fo t a ke U rn C (1 C-e--<Z� Greyn TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (509 /oZ TOTAL NUMBER OF BATHROOMS WELL WATER: YE NO—Ae!f ...(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 OWNER INFORMATION: FULL NAME OF APPLICANT &-SCk-n �� SOLE OWNER: YES NO OWNER PHONE# �p/ / 770 - Ip Q f0 ADDRESS_t...._i C'er1.S('vN Q CORPORATE OWNER:' CORPORATE ADDRESS: �`3� a n co r—k— z' a u-e✓l c-,A ify�A d !c n1 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 elf- 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asy. 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 FormsTOODAPP REV3-2019.doc f Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. fAYNSTA@I� 9 F.P.(Thomas)Lee NABS Daniel Luczkow-Alternate ate; 200 Main Street,Hyannis,MA 02601 Phone: (508)862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code,a permit is hereby granted to: Permit No: 757 Issue Date: 1/1/2021 DBA: SUPER STOP & SHOP #066 OWNER: STOP&SHOP SUPERMARKET CO. Location of Establishment: 3900 FALMOUTH ROAD.MARSTONS MILLS, MA 02648 Type of Business Permit: 'Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS,CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY : For Office Use Only: Initials: Town of Barnstable Date Paid AmtPd$ Inspectional Services m . . lG-I �i5�3 Cheek# f. Public Health Division --� -'��._ Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT...PERMIT APPLICATION.(Non Flavored) DATE NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: — GUO ��- ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: f� v `fJ C%OuA TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: OWNER'S NAME: t `(lAr� 11 - 3 OWNER'S PH#�� OWNER'S ADDRESS: Nb-k `; l CORPORATE NAME: A 6\1-OP W "�A CORPORATE ADDRESS: EP Q�h L� / I'P iat�'r OiAkATE FID# t ANNUAL: SEASONAL: DATES OF OPERATION: /_/ TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS). TOWN OF BARNSTABLE CODE/MA GENERAL.LAW INTERNET LINKS: ti TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httgs://ww.w.ecode360.com/33996392 ._._. MA GENERAL LAW CHAPTER 270/SECTION 6: , https://male6islature.:aov/Laws/GeneralLaws/PartIV/TitleI/Cha er270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: Y 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: . PRINTED NAME: Z5�10A;V(r 11 DATE: l3 / 1(0/ J0 I QA1Appfication Fonns\TOBACCO APP-NonFavor 12-18-19.docx i 5�0 ESTABLISHMENT'g NAME i TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9.of the Town of Barnstable Board of Health Regulation: Sales to Minors—4.371-9. Sale and Distribution of Tobacco Products.. i i 1, No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable a is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: .II lk A d Signature Pfinted Name Date Signa Printed Name Date Si a --Printed Name Date (( IZ)HO Si attire Printed a�N me Date 1J,11 b o Q Si ature Printed Name Date __ wi 2 i a re L-?l Printed Name Date nn� o n� Signatu a Printed Name Date r; Q:\Application Forms\TOBACCO APP-NonFavor 12-I 8-19.docx at i Commonwealth of Massachusetts Lcttcr ID:L10t3030464 m UM 290 r Department of Revenue Notice Darr..:Octobcr 30,2020 Geoffrey E.Snyder,Commissioner Account ID:CGL-10044051-295 all mass.govjdor RETAILER LICENSE FOR SALE OF CIGARETTES lII1lrlrltlri111111ttrrntllrlriltl11111lI�II�tnl�bh111r1 ATTN LICENSING DEPT STOP&SHOP SUPERMARKET CO LLC STOP&SHOP#001 1385 HANCOCK ST QUINCY MA 02169-5103 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3).Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.govimasstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617)887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday,8:30 a.m.to 4,30 p.m. DETACH HERE `f C" MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes y �trr,41�4v This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. STOP&SHOP SUPERMARKET CO LLC Account ID: CGL-10044051-295 STOP&SHOP SUPERMARKET#66 Location ID: 10044051-0288 3900 FALMOUTH RD License Number: 102377472 MARSTONS MILLS MA 02648-1855 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 30,2020 Expiration Date: September 30,2022 Bellaire, Dianna From: Mark Songer - 0066 <Mark.Songer@stopandshop.com> Sent: Monday,January 11, 2021 8:06 PM To: Bellaire, Dianna Cc: Deborah Seale - 0066; David Colameco - 0066 Subject: Re: 2021 Food Permit Stop and Shop Food/Tobacco permits for Town of Barnstable- IMPORTANT Attachments: License to Sell Cigaretts jpg Hi Dianna, Our store does not sell cigars or electronic delivery systems, sorry about the license to sell cigarettes. I will get the Application for permit to operate a food establishment in this week, sorry for the delay. Thanks, Mark Songer From: Bellaire, Dianna <Dianna.Bellaire@town.barnstable.ma.us> Sent: Monday,January 11, 2021 11:36 AM To: Mark Songer-0066<Mark.Songer@stopandshop.com> Cc: Bellaire, Dianna <Dianna.Bellaire@town.barnstable.ma.us> Subject: RE: 2021 Food Permit Stop and Shop Food/Tobacco permits for Town of Barnstable- IMPORTANT Hi, I didn't have a tobacco attachment. Do you sell cigars or electronic delivery systems? I will need a reply to this email saying you don't or copies of those licenses. There was no cigarette license attached to this email. Each Food Permit is 535.00 and please add the$10.00 late fee. You must provide the 2 food service food manager's certificates and one of them should be allergen trained. This would be for EACH store. Thank you for your help. The applications were sent back in November. 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 The.information contained in this electronic transmission("e-mail"),including any attachment(the"Information"),may be confidential or otherwise exempt from disclosure.It is for the addressee only.'Phis Infoiniation may be privileged and confidential work-product or a privileged and confidential communication.The Information may also be deliberative and pre-decisional in nature.As such,it is for internal use only."the Information m.av not be disclosed without the prior written consent of the Director of Public health and/or.the. Town Attorney's Office of the Town of Barnstable. If you have received this e-mail by mistake,please notify the sender and delete if from your. system.Please do not copy or.forward.it.Thank you for your cooperation.. 1 Bellaire, Dianna From: Karen Deluca <kdeluca@defoods.com> Sent: Tuesday,January 12, 2021 11:58 AM To: Bellaire, Dianna Cc: Karen Deluca Subject: KFC's 2021 Food Permit RE:???? KFC 314 Barnstable Road Hyannis Good Morning Dianna, I just called the health department looking for our new 2021.Food Permit and they suggested I email you. I never received the 2021 food permit and was hoping you could email me a copy. Thank you, Karen Caren DeLuca D.E. Foods 101 Accord Park Suite 104 Norwell MA 02061 781-982-0755 ext.3 �7 CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe!' i i Cl� KE Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. EMA Paul J.Canniff,D.M.D. 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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 757 Issue Date: 12/10/2019 DBA: SUPER STOP & SHOP #066 OWNER: STOP &SHOP SUPERMARKET CO, ATTN:LICENSING DEPT Location of Establishment: 3900 FALMOUTH ROAD. MARSTONS MILLS, MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020 RETAIL FOOD: $285.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: J oFTgy For Office T— Initials: Town of Barnstable } Date Paid Amt Pd$ . BAMST LE, : Inspectional Services crag 20-.17A40 ' Public Health Division Check# RFD MAy A Thomas McKean, Director 200 Main Street, Hyannis, NLA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE I a7 Iq NEW OWNERSHIP RENEWAL v NAME OF FOOD ESTABLISHMENT: Sit SGtoe W&& ADDRESS OF FOOD ESTABLISHMENT: t3Qoo ralmowd, Rai 1 ar5Ty!'c.S /" d S MAILING ADDRESS(IF DIFFERENT FROM ABOVE): L!'t°en5/Vl��l3$5NQ✓�crx� S�Q)jc cl MA a;?A&9 E-MAIL ADDRESS: SS. 57pr"2. vo(O(o. skwent&vu et—g a-y14l .C6 M— TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER: YES_NO V ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: (Y TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALER'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) OD 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*** REOUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT (5Wi2nr7e, Kesk-,K- SOLE OWNER: YES/D J_ OWNER PHONE# (Q f'7 `7 7G 8708 ADDRESS_ GideYt5G jr - l385-1-171UnMCC cS7L` owle)aq l )q oc-Pho ' It CORPORATE OWNER: /� 'TOP �' cJLlbO �L�2ek- harb:1—(-0 u-G- CORPORATE ADDRESS: I.3�J� /!Q✓I L}OL' (jU 1 nW PERSON IN CHARGE OF DAILY OPERATIONS: Dehoy-ak Seale- 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. Deborah S-eaJe- la i ao 1. 1`, eho-cak &ale- li i r /,P- n 2. 00rn PS r 0PrV 15_ 1 7 / ,,) .f SIGNATU OF APPLI ANT 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 1st to Dec. 3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. QAApplication FormsTOODAPP REV3-2019.doc ` �TME Only,For Office Use Initials: ,y ti Town of Barnstable Date P; Amt Pd$ Vim' $,, Inspectional Services HAM. �2® t6. Public Health Division Thomas McKean, Director ' 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE 7 NEW BUSINESS OWNERSHIP RENEWAL '✓ NAME OF TOBACCO ESTABLISHMENT: 4 i"UIIU ADDRESS OF TOBACCO ESTABLISHMENT: 3�00 '1(Y`6(A V 1 �d I"1(a;1(ST ms WAS> MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: LOW am TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (509 `7A- (c)72' (V)e Stvpt!Svp 3wperma4.t& OWNER'S NAME: L OWNER'S PH#41-7)270-12ffD. OWNER'S ADDRESS: G &)MCL ( CORPORATE ADDRESS: J b S�du EQ MA. CORPORATE ANNUAL:�� SEASONAL: DATES OF OPERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) A)Iia TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https://male islg ature.gov/Laws/GeneralLaws/PartIV/TitleI/Chai)ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY *** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: DATE: // /o?7/ ,Iq Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc Oil WI s, t is es r rs ent' i`" oa C a ter 3?�I � xce ved and u g . �� PROa t fIf Oct n' one I�assa�cE�usetts Ci neral Laws rt'ch es ri s the, o sac can uhder the #dscto Sea e n /" 5 � 1' � �'y WWO T'° mra- alea�tSi a t�rbacco produce;ss definedx herein t aINIOn uncle `= . $a sailnau, of BarnstaibEe not o ......'�icta, clef ded� r e � y he t , , � . > „ pyz�neis caald ovemrnentNdrtotcgr icyPv, W l�dn# {fl17 }1 tStt11tChSBC lS1 � �y wpf' I�1 4) l a�andr "a a.k,yv.cu' L Tom Ao� aEdd Section 171 4 0#the Town cif Barnstable B� cif / atgn ankh er n 6 of Ow"Ma s Cer�eralws n aPt 2t, Sect�c� Dat PO sr :+ .g W" !ate vo awl r 4 % n ' row r11., e > r *WqN , i Commonwealth of Massachusetts Letter ID:LOSS 1101440 WHO Department of Revenue Notice Date:September 25.2018 't Christopher C.Hardin?,Commissioner Account 1D:CGI:10044051-295 Ar01 mass.govAdor RETAILER.LICENSE_FOR SALE OF'.CIGARETTES Ilultt���ll�Irl�hlhllill�11N1I1�IIrIlllllrtill�ll'1111111t1 ATTN LICENSING DEPT STOP&SHOP SUPERMARKET CO LLC STOP&SHOP#001 1385 HANCOCK ST QUINCY MA 02169-5103 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T).Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.govdmasstaxconnect to view and re-print a copy of this license. If you.have any questions about your license,call us at(617)887-6367 or toll-free in Massachusetts at (800)392-6089, Monday through Friday,8:30 a.m. to 4:30 p.m. DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. STOP& SHOP SUPERMARKET CO LLC Account ID:CGL-10044051-295 STOP&SHOP SUPERMARKET#66 Location ID: 10044051-0288 3900 FALMOUTH RD License Number: 1333815296 MARSTONS MILLS MA 02648-1855 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable-and may suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2018 Expiration Date: September 30,2020 COMMONWEALTH OF MASSACHUSET S.- DEPARTMENT OF REVENUE PO BOX 7010 BOSTON,MA 02204 403C 0 STOP & SHOP SUPERMARKET CO LLC Notice Date: 06/15/12 1149 HARRISBURG PIKE CARLISLE PA 17013-1607 Taxpayer ID Number: 043 061 447 Dear Taxpayer, Below please find your Sales and Use.Registration Certificate (Form ST-1). Please cut along the dotted line and display at your place of business. Sincerely, Massachusetts Dept. of Revenue - - - - - - - --- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - --- - - -- - - - - - - - Massachusetts Department of Revenue sT-1 Customer Service Bureau PO Box 7010 Boston, MA 02204 ES.ANI7 The vendor herein named is registered to sell tangible personal property at retail or for resale, pursuant to the General Laws, Chapters 62C, 64H and 641. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct ST-1 can be issued. IDENTIFICATION STOP & SHOP SUPERMARKET CO LLC NUMBER SUPER STOP& SHOP ' -j4'- (p W 043-061-447 3900 FALMOUTH RD MARSTON MILLS MA 02648-1855 ISSUE DATE 01/29/04 This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OF REVENUE v . Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNSTABLE, : ` Paul J.Canniff,D.M.D. F.P. Thomas Lee Alternate sr, $ 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 757 Issue Date: 1/1/2020 DBA: SUPER STOP & SHOP #066 OWNER: STOP &SHOP SUPERMARKET CO, ATTWLICENSING DEPT Location of Establishment: 3900 FALMOUTH ROAD. MARSTONS MILLS, MA 02648 Type of Business Permit: Non-Flavored Annual _ Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY I ` flf�F1f' Town of Barnstable BOARD OF HEALTH 'L Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. RMINS`ABLL John T.Norman M4� ,� 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 757 Issue Date: 12/20/18 DBA: SUPER STOP & SHOP #066 OWNER: STOP & SHOP SUPERMARKET CO, ATTWLICENSING DEPT Location of Establishment: 3900 FALMOUTH ROAD. MARSTONS MILLS MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 Outdool-Seating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR: 2019 RETAIL FOOD: $285.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: -- -- — --—- -- -- MOBILE-FOOD: MOBILE-ICE CREAM: CA FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: ; PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE l Restrictions: oFtNME r°w Initials: For Office Use Only:Town of Barnstable F mmgrABLE ` Inspectional Services Date Paid Amt Pd$ 1639. •0� Cash ATf639. Public Health Division check# Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ,l APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 12 V I Y NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: �tp� �V)0 pSaptV mA tf #V ADDRESS OF FOOD ESTABLISHMENT: �C w MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Y, I,f.I A� �z��� U ��—� E-MAIL ADDRESS: SLSaA . �V)L C6 6 ,,oyf , uy TELEPHONE NUMBER OF FOOD ESTABLISHMENT:) -1b TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO Y ... (ANNUAL WATER ANALYSIS REQUIRED) s` ANNUAL: V� SEASONAL: DATES OF OPERATION: l�P/K TO 1"'O / I /r Sw�`L C1 P NUMBER OF SEATS: INSIDE: U OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISIFYIENT: (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) Q ) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL, MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q\Application FormsTOODAPPREV2018.doc I OWNER INFORMATION: PLEASE CALL 508-862-4644 � --I �/ FULL NAME OF APPLICANT 1�1SCAY) �0 1� SOLE OWNER: YES NO OWNER PHONE# ADDRESS CORPORATE OWNER: FEDERAL ID NO. : CORPORATE ADDRESS: 13kS5 �UK-Dd-s-� Lk;l 6 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 ('�eru I�, l i a�i �'D�3i. ebXah Snk I 9 izoav 2.1�bo-rc�,k Scede- a o Lo ---f4 AM 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/bealthdivision/applications.asy. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec.3 I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:Wpplication FormsT00DAPPREV2018.doc Town of Barnstable • Regulatory Services Department MASS. Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-7904644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT h*SWrNAME OF APPLICANT S�'p p Spa SVQ- X Ma-A- kct DB/A 39OD �-CJ MO tktk-, MI � (S STREET ADDRESS 5z) � - 41� - )2-'� V _ TELEPHONE # FID# Do you currently possess a state license to sell tobacco products? Yes J( No Each employee who sells tobacco products must receive and understand the Sections VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy- provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided-on the next page). Each employee who sells tobacco products must sign the mployee Signature Form (provided herein). /A/1-2/i Signature Date Q:\Application Forms\TOBACCO APP2018 dob.docx 00 Commonwealth of hiassacdusetts Letter ID:L088 i 101440 Department of Revenue Notice Date:September 25.2018 i t Christopher C,Harding.Commissioner Account ID:CGI.10044051-295 f ok mass.govfdor RETAILER LICENSE FOR SALE OF CIGARETTES lnll� hilltlrl41lu!!Il�11N11111rllJill l��huh1111111�1 ATTN LICENSING DEPT STOP&SHOP SUPERMARKET CO LLC STOP&SHOP#001 1385 HANCOCK ST QUINCY MA 02169-5103 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T).Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617)887-6367 or toll-free in Massachusetts at . (800)392-6089, Monday through Friday,8:30 a.m. to 4:30 p.m. DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T A y Retailer License for Sale of Cigarettes 7 Sv 0** This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. STOP&SHOP SUPERMARKET CO LLC Account ID:CGL-10044051-295 STOP& SHOP SUPERMARKET#66 Location ID: 10044051-0288 3900 FALMOUTH RD License Number: 1333815296 MARSTONS MILLS MA 02648-1855 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2018 Expiration Date: September 30,2020 r Sr ti r r �" ✓ r� s z E - Ti llwAW mar �Km y WIT ft—a � 19 %a Mal t am x � 4 r s , ar r v i� e f fl S y' x r X x " r � r F i r' a 01/154019 14:08 1-508-428-7242 STOP&SHOP PAGE 01/01 Town of Barnstable For Office Use Onlw. Initials: � T Date Pald $ 's Inspectional Services Check# ('sch NAM Public Health Dm`sio» a r 200 Main Streei;Hyannis MA 02601 Moe: 508-790-4644 Thomas k McKen,RS.C140 FAX: 508-790-6304 j Director of Public Health Fee:$85.00 MAIL TO:TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS;MA,02601 FAX 508 790-6304 PLEASE INCTATDF.THE RF,QUIRED FEE O1F$85.00 APPLICATION FORA TOBACCO SALES PERMIT To Qn�c J�o • ESTABLISHMENT NAME (D/B A) 3900 IN i ► lAr��,A-1 !r Iltl S ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OWNER'S NAME: LAST FIBS' MIDDLE � In. Seake Q & . mtv\ SOBS- 4l61g-/,2 7 EMAIL PHONE# FEDERAL RW Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must r I've and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270,Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form (provided herein). Signature Date I.. Q:1Appiication ForTs%TOBACCO APP2019 dob.docx 01/1-5%2019 14:12 1-508-428-7242 STOP&SHOP PAGE 01/01 ESTABLISHMENT'S NAME TOBACCOSALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one(21). Below is Seetiol371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors-fi 371<-9.50e and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age-in the Town of Barnstable is 21 years of age. — - 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall.verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Vcrificatipn is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town, of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: rA )&,taa �1�qery I h!9, ature Printod NOnc yeti i Prmted Name Date gnature Printed Namc *� Gate j // J,� CA ro Signaupt Printed Name Date( "Sign anffa Printed Name Date Signature Printed Name—0 Date /' �aSor1 �S'�1Co�l �� /19 u Printed Name Date TOBACCO SALES TO MINORS PROIIIBITED BY MASS,A.CHUSETTS GENERAL LAWS Q\Application FortDs�TOBACCO APP2019 dob.docx Op IKE T TOWN OF BARNSTABLE. HEALTH.INSPECTOR's Establishment Name: '�" " J r� Date:I Cy ( 2- Page: I of t "�o 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 M639• �0�� HYANNIS,MA 02601 - - M-8 -FRI.62�644 508 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT Name 13160 SILM Date 7 I Z/ Tvoe of T Ins ec ion outine //- Address h,(f Risk Food Se Re-inspection (.t/t S/��! IJIL cc��1i Level etail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation p /M I � � Tele Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) ���� Time Bed&Breakfast HACCP S (�� f` In: Io',3 b Other �, Inspector ,V � � Out: Each violation checked re uires 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) ❑ i �� _�frs� FOOD PROTECTION MANAGEMENT ❑ 1 .Prevention of Contamination.from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties 13.Handwash Facilities V r I - �J� O / EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 3 6 �L _ 0� ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals D �•� r nip f' 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 I�� �� �� 0 B n�� v� ❑ 7.Conformance with Approved Procedures/HACCP Plans Hot and Cold Holding ►�w,r,� //_ PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control 1Lw't-C 1r ❑8.Se ration/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) .Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for H P )_ //.,Lr /� C _/ ❑ 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 L/ Critical(C)violations marked must be corrected immediately. blue&red items)) ,1 n '2� Corrective Action Required: Q/ ,/� Np ❑ Yes y Non-critical(N)violations must be corrected immediately or Overall Rating Y/ within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusio Re' ct-ii Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items F] Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Emergency Closure Other: Voluntary Disposal ❑ 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical, results in an F. 25.Equipment and Utensils (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)(590.005) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility aggrieved b 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 lack of y ty (FC-6)(590.007) a99 Y Y 9 g q violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 on- ritical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION, Inspector's Sig a re Pri J Oe�N 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign ure 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.) f FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003 A) Assi nment of Responsibility* 8 Cross-contamination r. Law Cooled to 41°F/45°F Within 4 Hours* ( g14 Food or Color Additives 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-20212- 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 Uhapproved 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 3-302.1](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-]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 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* _ 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 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 7-203.11 Toxic Containers-Prohibitidns* ( ) q __ _. _ _ 3 590.003(D) Exclusions and Restrictions*590.003(E) Removal of Exclusions and Restricti 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.L4(A)(B)Resumed Food and Reservi of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP ons Disposition of Adulterated 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 Warewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed Sprouts Not Served* 3-201.12 Food in a Hermetically Sealed Container Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Watei* - Concentration and Hardness* 183-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 57101.11 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* EJ/-rive 1112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell _ _ Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-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 Stuffin Containin Fish,Meat,Poultry or 3-201;15 Molluscan Shellfish from NSSP Listed _ Chemical* g g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165'F 15 sec* ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 10 Proper,Adequate Handwashing 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 Requirements.shouldpractices be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C 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 * 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. 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 Conformance with Approved Procedures* S:590Fonnback6-2doc *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. oF1"r TOWN OF BARNSTABLE HEALTH INSPECTOR-s Establishment Name: Date: 2- Page: 2 of ' ti OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.K ' BARNSTABLE. • 200 MAIN STREET 3:MON. o FRI.I' Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS, MA 02601 M 5088 -- 62-4644 No Reference R-;Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPCTI �jDrFo MAC� ON REPORT �- 3 o Name S Date l, 2' Tyne of Type of Inspection �3 ODera6on(sl < Address M Risk OPISod Service - pection Level Kera-Ir Previous Inspection JU AYA Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness aVroc Caterer General Complaint - Time Bed&Breakfast HACCP Person in Charge(PIC) ��.f In: 10I 30 Other I✓k 66A ,S -C. .-7 c Inspector S 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) ❑ )"\ V"`� �� Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ I (� Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ l/ C�1�- 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 / a FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) c ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ^ ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling w�I ❑ 7.Conformance with Approved Procedures/HACCP Plans E�Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control eparation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP f .a' %_ / d j� ❑ 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 must be corrected immediately. (blue&red items) u 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. FOEOmbat lunary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the itemsr ochecked 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 9 ardless 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 6=One critical violation and less than non-critical violations re 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. if if no critical violations observed,4 too 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 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 violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4g8n- 1 violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's S PH t31.Dumpster screened from public viewPermit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signa Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N v Dumpster Screen? Y N Violation related to Foodborne Illness Violation 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* :I 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12' Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in=Charge Duties - - 3-302.14_ Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*Other* 590.004(F)3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Gharge.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 Se aration-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* 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 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* 4-501.11-1 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 Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 1 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 5-1.01.11 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* Effecrive 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 g Caught Molluscan Contact Surfaces of Equipment* Shellfish* ' " 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 5orary and - ide in cater- * -- - Ratites-165°F 15 sec* in mobile food,temporary and residential Sources g. P azY 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* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms*_ 3-401.11(A)(1)(b) All Other -145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requiremenpractices ts should be debited under#29-Special $ 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* 1 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* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13 Handwashing Facilities 3-202.18 Shellstock Identification* i 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 Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance t° 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* 1 130. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* 'fl 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. �p iNE► TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date:- Page: of 3 OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSrABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified Me39. �•� HYANNIS, MA 02601 MON.-FRI. No Reference .R-Red Item PLEASE PRINT CLEARLY �1°rF0 MPS 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name S S Date Z Tvoe of f Inspection O s utine Address �� ,1/l Risk Re-inspection Level Retail Previous Inspection l Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary. Suspect Illness, aCeeg rh Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP (y�l��W�1 BGL �2-id. tl,"� In: l�r 3b Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. l�- 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 andwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives (� � 41 ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) i ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ,{^ ❑ 5.Receiving/Condition ❑ 17.Reheating I vA 0 ags/Records/Accuracy of Ingredient Statements ❑ 18. oling /l'S/ ILA V(❑ 7.Conformance with Approved Procedures/HACCP Plans 9.Hot and Cold Holding J 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 � I 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 El 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.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 6=One critical violation and less than non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have 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) g violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION• Inspector's Signat a Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted. Y N C 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* * * 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12* Additives 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 orTozi silbstances 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* g3-501.16(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* Applicants* - - 3-302.11(A) Food Protection* 7-201.11 Separation-Storage*g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(13) 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 -- -y Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* * Raw Seed Sprouts Not Served* y i Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* - 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16-' Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Clean Utensils and Food Contact Surfaces of 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* effil°"°e 1i1/2001 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) Pouttry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 1 4-703.11 Methods of Sanitization-Hot Water and Stuffin 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 1 p Proper,Adequate Handwashing g' P ry 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* - __27301.12 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 Reheatingor klot 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 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* L 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 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 1 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 29. 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 590.001Q. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °Ft rqr TOWN OF BARNSTABLE. ALTH INSPECTOR'S Establishment Name: Date: Page: Of ta_ ,(ai/' OFFICE HOURS HE PUBLIC HEALTH DIVISION. 8:00-9:30 A.M. BARE. 200 MAIN STREET l I 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MA55. ` 1111 I MON.-FRI. fib, M. p.• HYANNIS,MA 02601 sos-ss24saa No Reference R-Red Item PLEASE PRINT CLEARLY , rFA MP'� FOOD)ESTABLISHMENT INSP ION R RT . Name Date Tyne of Type of Inspection pen O s Routine Address k pod Se i Re-inspection -41 \ el Previous Inspection Telephone Residential Kitchen - Mobile 2re opera' Owner HACCP YIN Temporary Slispealliness Caterer General Complaint Person in Charge(PIC) Time Bed 8 Breakfast HACCP Other Inspect o t: l ,. A-611 Mil 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) ❑ i Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ .� FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands i , ❑ 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 TIMElrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures Wfr ❑ 5.Receiving/Condition ❑ 17.Reheating n ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding 1 r� 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 V Critical(C)violations marked must be corrected immediately. (blue&red items) ❑ ❑ Non-critical(N)violations must be corrected immediately or Overall Rating J Corrective Action Required: No Yes I within 90 days as determined by the Board of Health. g ❑ 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 regardless of the number of critical,results in an F.. 25.Equipment and Utensil s (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations if no critical violations observed,4 too 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 o 8 than i non-critical. . f 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 8npn-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 g _ = 29.Special Requirements (590.009) within 10 days of receipt of this order. violati to 8npn-critical violatio s C 30.Other DATE OF RE-INSPECTION: Inspe is Sig ture Print: 31.Dumpster screened from public view. Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N .S Violations related to Foodborne Illness - Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) 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* PHF Hot and Cold Holding . Contamination from Raw Ingredients 15 Poisonous Identifying Information-Original Containers Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each * 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 3-302.11(A) Food Protection* 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 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 orce,of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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 Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective t°rzoot 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 in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) ( ) ( ) Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By _ 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority_ 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* 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 7 7 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 * (Blue Items 23-30) 3-202.15 Package Integrity (C)� Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3 403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 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 1 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision j 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* - 8-103.12 Conformance with Approved Procedures* S:590Fomtback6-2doc '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. �64 �F THE ror, ' ` TOWN OF BARNSTABLE HEALTH INSPECTOR•s Establishment Name: _' Date: Page: of 3- 4 OFFICE HOURS -r / AR E° PUBLIC 0 MAIN STREET DIVISION8:00-9:30 A.M. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MA.- 4 MON.-FRI. �p 1639.G 0 _ HYANNIS,MA 02601 508-862-4644 No Reference R-Red I em PLEASE PRINT CLEARLY- .. 'EOM :FOOD E ABLISHMENT INSP CT ON REPORT Name Date Type of Type of Inspection Operation(s) Routine Address Risky- Food Service Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation ` Owner HACCP Y/N Temporary Suspect Illness i' Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP t3 In: Other Inspector Out: d Each violation checked requires an xplanation 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 TIME/TEMPERATURE-CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures r� / ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary.Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 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=IF 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 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspec I of Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC IS 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* - 19 PHF Hot and Cold Holding g 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 7-102.11 Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130°F* Applicants* * - 7-201.11 Separation-Storage* - 20 Time as a Public Health Control 3-302.11(A) Food Protection 590.003 F Responsibility of A Food Employee or An 7-202.11 Restriction-Presence and Use* * O P - y3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) 1 Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Suuaces 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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 4-601.1](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* eg cn-rnnoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed. * Stuffing Containing Fish,Meat,Poultry or 590.009 A 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 Game and Wild Mushrooms Approved By ( )(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 $ Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165*F 15 sec* Requirements. 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15, Package Integrity* g g 3-403.11(C) Commercially Processed RTE Food-140'F 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* 13 Handwashing Facilities 3-501.14(A) _ Cooling Cooked PHFs from 140°F to 70'F ConvenientlyLocated and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6 2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 GMR 590.000. tHE 1p TOWN OF BARNSTABLE .HEALTH INSPECTORS Establishment Name• HISM V:�MT Date: Page: of ti PUBLIC HEALTH DIVISION OFFICE HOURS8:00-9:30A.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 02601 M-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY MP'� 50862-4644 FOOD ES BLISHMENT INSP TI N REPORT Name. Date a of Type of Inspection era io s Routine Address Risk Food Service Re-inspection VV Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint r Person in Charge(PIC) Time Bed&Breakfast HACCP Other Inspector D N11 In A uu � Each violation checked requires an explanation on the narrative p e(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) ❑ 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) ❑ 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 ❑ go Emergency Closure Voluntary Disposal Other: Embargo 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 6=One critical violation and less than 4von-critical violations 9 ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than.9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. y 29.Special Requirements (590.009) Within 10 days of receip t of this order. violation;4 to 8. on- r tical violations=C. 30.Other DATE OF RE-INSPECTION: Inspe is t re Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signa U 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control Charge* 7.202.12 Conditions of Us 7-202.11 Restriction-Presence and Use* Applicant To Report To The Person In Charge* 3-501.19 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or 3-302.15 Washing Fruits and Vegetables * e* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _ REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) ' Food 7.204.14 1 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* 3-801.118) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.1-11 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 96 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* 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* Ef°d-urrtoor 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 3-201.15 Molluscan Shellfish from NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.1](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. $ 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 PreventingContamination When Tasting* * Blue Items 23-30) 3-202.15 Package Integrity* g 3 403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome 12 Prevention of Contamination from Hands 3-101.11 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* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F. Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 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 .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. • i DAVID LEE Regional Manager c. 980.402.9431 dleo@hisshosushi.com I is a sr eat da, for uslhl!C' °F THE rq TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: - Date: �l ll/ Page: of 1 q OFFICE HOURS 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 MON.HYANNIS,MA 02601 - 644 No Reference R-Red Item PLEASE PRINT CLEARLY �prFD MPS p,0 � 508-88-862-464 FOOD ESTABLISHMENT INSPECTION REPORT G . Name Dat / e of Tvoe of Ins ep ction _ �`�' Operation(s) Routine Address Risk Re-inspection Level Previous Inspection Telephone Residential Kitchen Date: 41 Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness v Caterer a Complain Person in Charge(PIC Time Bed&Breakfast OC 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) r v� ❑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 Asa 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 ElYes Non-critical(N)violations must be corrected immediately or Overall Rating �(�I \ 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 6=One critical violation and less than 4non-critical violations )( ) 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, 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 9 p,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 anon-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8non-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 L Permit Posted? Y N Grease Trap Previous Pumping,Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N RIC'S Sign atur 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods. 3-302.14 Protection from Unapproved Additives** 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 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*590.003(E) Removal of Exclusions and Disposition of Adulterated or 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Resumed Food and Rated or of Food*Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP Restrictions 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* 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 5-101.11 Drinking Water from an Approved System 11 Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef ai°e 1112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency 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 Surf of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources 10 Proper,Adequate Handwashing g' �� 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. 2-301.14 When to Wash* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 3-401.11( )( )(b) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices Requirements.should be debited under#29-Special 5 Receiving/Condition 2401.11 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* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°17 Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 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. �)7 oF,H roar TOWN OF BARNSTABLE HEATH INSPECTOR'S Establishment Name: Date: - ' Iq Page: I of P� qo OFFICE HOURS a of PUBLIC HEALTH DIVISION 9:00-9:30A.M. 200 MAIN STREET 3:30-4:30 F.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified BARNSTABLE. ` MON.-FRI. MASS. �p ,,,q,a 0� HYANNIS, MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT 01-7 ICI,�r e� V"',b � k "f,% Atog', Name Dat TvDe of Type of Inspection O Rout' Addres Risk ood ervi - section Level et i ` rewo s nspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector , Out: t Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. e 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 v ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash FacilitiesklLm f EMPLOYEE HEALTH PROTECTION FROM CHEMICALS l ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 4f- ❑ 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 t t_`1 Wel ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.CoolingLPf ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time Asa Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) :V140 ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP r `J or ❑ 10.I�roper Adequate Handwashing CONSUMER ADVISORY VV ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations �---� IX Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: o ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating 5r within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑fRe-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. F is 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t scored automatically lack of 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 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or la 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. violation,4 to 8npn-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: j 31.Dumpster screened from public view I 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:jal Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y NweSDumpster Screen? Y N ,__ _ _ .4r�.1:�'-1�•�•s.-.-...----a.^--ter..-.,.•tip+,,,•.-•},,,.......R •--"',��, .s..� r. . -�. t-�,,. y-n _ -�a""'^,•,f'-,'+...i-"_.., ..�---.y, -' ti.r-----•sue�--^.�.r-w�.--•.----...^vw^r...-. _ ....yp,-::ti--�.. .. - `�•i `.-"7-•:._. _.._-,�a.r,::.s...n�•.°_s.._ _ - -.. � ..s.- r..e-- Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions g 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 15 590.004(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* Require Reporting by Food Employees and Contamination from the Environment 7-102.11 Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130°F* * * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 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 of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(1--)) 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 1 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* 3-40111A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective uuzooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-1 1 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) 155 Ratites,Injected Meats-I55°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish*! 3-40111(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-70311 Methods of Sanitization-Hat Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A Violations of Section 590.009 A - D in cater- 3-201.15 Molluscan Shellfish from NSSP Listed , Chemical* ( )-�) ( ) ( ) Ratites-165°F 15 sec* Sources* 70. 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 3202.18 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 1 7 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 CommerciallyProcessed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands ( ) g illness interventions and risk factors listed above,can be found in the 3-101.11 Food Safe and Unadulterated* 3-403.11E Remaining Unsliced Portions of Beef Roasts* 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 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Oackaging 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. ) [,�3( Op THE Tok, TOWN OF BARNSTABLE. _ HEALTH wSPECTOR,s Establishment Name: Date: gage: of + q OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. • 200 MAIN STREET 3:3o-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MON.67.A 0� HYANNIS,MA 02601 08-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY. rFD MP'� 508-862-4644 F OD ESTABLISHMENT INSP CT ON REPORT Name Date a of Type of Inspection 61 O e Routine ,. Address - Ris od Servi -nspection r -- Level t Telephone Residential Kitchen Date: ( Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed 8 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 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) 5 ❑ 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 C ,.... 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 (FC4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to boon-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,noh-critical. If no critical water,sewage back-up,infestation of rodents or insects,or tack of ( )( ) be in writing and submitted to the Board of Health at the-above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI 's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter,Posted Y,. N (//,•l�� Dumpster Screen? Y N �� r 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 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590003(C) Responsibility of the Person-in-Charge to Other* 7-10211 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* . Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction Presence an tion-Pd Use* 590.003(F) Responsibility of A Food Employee or An 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003 Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* (D) REQUIREMENTS FOR 3-306.14(A)(B)[Discarding turned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions sposition of Adulterated or Contaminated od 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources od 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 17.206.12 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* Raw Seed Sprouts Not Served* 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. 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 Eggs 5-101.11 Drinking Water from an Approved System* 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* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009 A D Violations of Section 590.009 A D in cater- Chemical ( )-( ) ( )-( ) Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority, 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 11 Good Hygienic Practices practices should be debited under#29-Special 3-201.17 Game Animals* 17 Reheating for Hot Holding 2-401.111 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g� g g 3-403.11(A)&(D) PHFs 165°F IS sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity* g g 3-403.11(C) Commercially Processed RTE Food-140°F 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* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* �3-501.14(11) 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 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* - 8-103.12 Conformance with Approved Procedures* S:590Fofmback6-2doc r *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. " oF.HKE. TOWN OF BARNSTABLE HEATH INSPECTORS Establishment Name: Date:,:: 4j Page: of ti OFFICE HOURS i ARNnAB,Eoz PUBLIC ALTH RETSION 8:00-9:30 A.M. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ..S HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE FRINT CLEARLY 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name Date Type of Tyne of Inspection (I itO s Routine Risk ;.� rl- Address Level sous nspection Telephone sidential 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 q, FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) l�Y� ❑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 �n ❑.11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories IC/Xl(J1 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. I ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items Embar o 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 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 6 non-critical violations if no critical violations observed,4 too 6 von-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 i.non-critical. If f critical ' water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility .(FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 7 to a 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, non-critical violations. If i critical refrigeration. violation,4 to a 29.Special Requirements (590.009) within 10 days of receipt of this order. non-critical C.violations= 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N P- Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y - N J. CQ )To Dumpster Screen? Y N P-a�, Violations related to Foodborne•illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* L a Cross-contamination L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold-Holding 2-103.11 Person-in-Chazge Duties - 3-302.14. _ Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Tvzic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F *--- - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-.Original Containers*7-102.11 Common Name-Working Containers 590.004(F) P g * 2 590.003(C) Responsibility of the Person-.in-Charge to- Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* � 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reaervior of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* 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* 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* Eff cdw 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* 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* 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 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* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under 929-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity* g g 3-003.11(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 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 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27, physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .00.8 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. � TOWN OF BARNSTAB.LE HEALTH INSPECTORS Establishment Name: STOP 4L •r Date: � � Page:, of q OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. - 3:30-4:30 P.M. Code C Critical Item F VIOLATION/PLAN OF CORRECTION Date Verified BARNSTABLE. ' 200 MAIN STREET Item DESCRIPTION O MON.-FRI. ,Ass• m PL S RIN L RLY No Reference R-R d Item E gip t639, �0�• HYANNIS,MA 02601 508-862-4644 - " l A 0M, MP'� OOD ESTABLISHMENT INSPE T N REPORT Name Date vne of Tvue of Inspection p �Re; �. . Address Risk ervi Level et ction Telephone B Residential Kitchen Date: VAn Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP n, Other Inspector LLUM 1111k2m Each violation checked re wires an explanation on the narrative age q s)and a citation of specific provision(s)violated. O Violations Related to Foodborm Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ 3 Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ LA - 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 I ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) o ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures AC ❑ 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 ,1,174 PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control A 0 eV A ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing I] 21.Food and Food Preparation for H P " ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked-must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. ob if no critical violations ob 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 less than o 6 non-critical violations served,4 to 6npn-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC75)(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 be in writing and submitted to the Board of Health at the above address violations observed,7 to 8npn-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.009) 9 vio Io 4 to 8 non-critical violatio = 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other PATE OF RE INSPECTION: Insp is 'ignatur � T,��� 31.Dumpster screened from public view G Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatur Print: / Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N �� C / 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 L 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15- Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F Applicants* 3-302.11(A) Food Protection* 7-202.11 Separation-Storage* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-501.19 Time as a Public Health Control* * 3-302.15 Washing Fruits and Vegetables 7.202.12 Conditions of Use* Applicant To Report To The Person In Charge * 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils ( ) 4 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR- 3-306.14(A)(B)Returned Food and Reared or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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* 3-401.11 A(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 crave 111/2001 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* Contact Surfaces of Equipment* * min 3-302.13 Pasteurized Eggs Substitute for Raw Shell B 1 Shellfish and Fish From an Approved Source 3-401.11( )( )(2) Pork and Beef Roast-130°F 121 Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g �' 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C Game and Wild Mushrooms Approved By 2301.11 Clean Condition-Hands and Arms* )(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under - Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* Requirements. 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) 1=212 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* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70'17 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 3-501.14 Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* 5-204.11 Location and Placement B) g 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005 Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) labeling of Ingredients* Supplied with Soap and hand Drying Devices 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Physical Facility FC-6 .007 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 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. oF1KE row v TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. % BARN3rABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MAss. HYANNIS MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY , �A 019•n` 508-862-4644 'FDN1P� FPOD ESTAB ISHMENT INSP CTI N REPORT Name Date a of Type of Inspection O e a ' s Routine Address Risk o Servi spec Level etail ous-I ection ^ Telephone Resl ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness PA bZ4rit K-Zz� 0 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 n ❑ 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 X2 ❑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 I AA i I 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 I❑ es Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. FOEOmbargo tary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension ffiC N Ocial Order for Correction:Based on an inspection today,the items ❑ 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 t 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 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 anon-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. vio 4 to 8non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Ins ctor' Wav) Print:31.Dumpster screened from public viewPermit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Si a 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) [Demonstration signment of Responsibility* 6 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 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 1 g Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 7-202.11 Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130°F* 3-302.11(A) Food Protection* Applicants* - 7- 01.11 Separation-Storage* 20 Time as a Public Health Control P 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction- resence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservi- of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 • Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111- Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* _ 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 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY * Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water 3-401.11A(1)(2) Eggs-155°F 15 sec 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* 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* 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* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-40 1.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 590.009 A 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* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* (Blue Items 23-30) 3-403.11(C) Commercially Processed RTE Food-140°F* Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands 3-101.11 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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 TagsiRecords:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* oc on an acemen Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance * Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006. 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 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. l0e oF. r TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Pag of OFFICE HOURS ARN�Eoi PUB2 0 MAN STREET 3:30-4:30 P.M. DIVISIONLIC HEALTH : 0'-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. p MON.-FRI. �p +639•p.0 HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item_ PLEASE PRINT CLEARLY tFD MP'� FOOD,ESTAALISHMENT INSPECTION REPORT - �j s Name Date Jype of Type of Inspection Climration(s) Routine Address Risk Food Service Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary. Suspect Illness i Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires a4 xplanation On the narrative page(s)and a citation of specific provision(s)violated. �y Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding i PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food Contact Surfaces Cleaning and Sanitizing 21.Food and Food Preparation for HSP �*_ 0.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non=critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils FC-4 590.005 B=One critical violation and less than 4non-critical violations 9 ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 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 g vio 4 to 8 n n-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspe is Si ur Print• 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC s Signat , Prin Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y• . N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 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 5 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* 59 4(F 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-501.19 Time as a Public Health Control* 3-302.15 Washing Fruits and Vegetables * Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003 D Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* ( ) 3-306.14(A)(B)Returned Food and Reservice of Food* REQUIREMENTS FOR - 590.003(E) Removal of Exclusions and Restrictions 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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* I Concentration and Hardness* 3-401.I IA(1)(2) Eggs-155'17 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* 3-40 1.11(A)(2) Comminuted Fish,Meats&Game Pathogens* e//cnmc rnnoor 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* 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 ¢Y 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* 10 Ratites-165°F 15 sec*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. * 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms ( )( )( ) * 11 Good Hygienic Practices practices should be debited under#29-Special 3-201.17 Game Animals 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165`F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities L 83-501.14(A) Cooling Cooked PHFs from 140`F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70`F to 41'F/45°F Item I Good Retail Practices FC 1590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41`F/45'F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. 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. �p 1194E Tq, < ` TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: G ` Date: /`�` Page: of OFFICE HOURSIf P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M. 9ARNSTABLH. i 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. $• MON.-FRI. p ,639.p�m HYANNIS,MA02601 508-862-46" No Reference R Red Item PLEASE PRINT CLEARLY rFON1P' FOOD ESTABLISHMENT I N S PEJJC T ION REPORT Name Date Tvue of jyRe of Inspection n s -7- Address Risk pod Se Re-inspectio &T/70 I0 I fl �In a Telephone Residential Kitchen Date: Mobile Pre-ope o Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge.(PIC) Time Bed&Breakfast HACCP Other InspectorI AA A u . Each violation checked requires an explanation on the narrativ page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors Red Items) - L 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 7b� V ❑ 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) It ❑ 9.Food Contact Surfaces Cleaning and.Sanitizing ❑ 21.Food and Food Preparation for HSPpp p �' ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORYho�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: N Yes Non-critical N violations must be corrected immediately or o ( ) Y Overall Rating - within 90 days as determined by the Board of Health. g ❑ 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 9.ardless 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 non-critical violations re if no critical violations observed,4 too 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 n-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 no -criti al violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. ation,4 to 8npn-critical la roA,-C. 30.Other DATE OF RE-INSPECTION: ecto's ' a e m Print: 31.Dumpster screened from public view IP77 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatur Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Qom, 1 Q�4-r \ O c�JJ '�.t� � 0� 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* * * 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14' Protection from-Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F -EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) * 2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16A 7-]02.11 Common Name-Working Containers* - ( ) * Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 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 AdulteReserrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition ofAduIterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 ' Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-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-lOLl1 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate � 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 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* 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* 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* 3401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. radicsshould be debited under 929-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3 403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 She Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 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' I 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 HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 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. f Miorandi, Donna From: James Caeiro - 0066 <James.Caeiro@stopandshop.com> Sent: Wednesday, October 9, 2019 5:10 PM To: Miorandi, Donna Cc: Deborah Seale - 0066; David Colameco -`0066;James Couture - 0066 Subject: Stop & Shop Store 66 Marston's Mills Good Afternoon Donna, Just a quick update on where we stand with some items that needed to be addressed. The Deli Hot Case has a ticket in with an ETA for service on 11/11/19. Ive reached out to the maintenance office and told them per the board of health we need to ensure that all parts of the hot case are in working condition and to expedite the process. In the mean time the store continues to monitor temps on all cooked foods and to pull off shelf after 2 hours. Ive reached out to Q/A about best ipractices when it comes to coding/dating opened product in our Deli Service Case. In the mean time we will print out blank labels and associates will sharpie the date. General Housekeeping/ Deep Cleaning in the Deli Case and Bakery Food Prep Area -on going. Seafood Banister repair has an ETA of 11/11/19 Thank You, James Caeiro ASM - Perishable Manager Store 66 Marston's Mills Work (508)-428-1278 Cell (508)-577-2166 Fax (508)-428-7242 This e-mail (including any attachments) may contain information that is private, confidential, or protected by attorney-client or other privilege. If you received this e-mail in error, please delete it from your system without copying it and notify sender by reply e-mail. CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe! 'o/d L% f -1 6-1- �p tNE Tq, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: : ` Date: Page: of 1 OFFICE HOURS P ° Y PUBLIC HEALTH DIVISION 6:00-9:30 A.M. i enansTaeLe. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS.�A 639•a�0� 1�' HYANNIS, MA 02601 508-62-4Rsaa I. No Reference R-Red Item PLEASE PRINT CLEARLY rFoMP� 444 FOOD E TABLISHMENT INSPEC ION REPORT A Name lr Date Ins ec ion s Routine Address Risk ood Serv' spe lion Level e Prew Telephone Residential,Kitchen Dat .. Mobile Pre-ope I Owner HACCP YIN Temporary Suspect Illness Caterer General Compl t Person in Charge(PIC) Time Bed&Breakfast HACCP Other Inspector t: 71 Each violation checked requires an explanat on on the narrati 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) AO Action as determined by the Board of Health. Allergen Awareness 590.009(G) El1 N FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 0 ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS OfyeMl� '7 Ize ❑ 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) A , 71, ❑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 ❑CC20.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 ) VO Iq ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories L� t6 6, N Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations u / i Critical(C)violations marked must be corrected immediately. (blue&red items) L-V"� Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: _X 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 6=One critical violation and less than 4nonscritical violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have 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-criti al viol tions. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 to 8 non-critical violati s= 29.Special Requirements (590.009) within 10 days of receipt of this order. S t 's Sign 30.Other PATE OF RE-INSPECTION: I s re Q, ' 31.Dumpster screened from public view 0 N Permit Posted . Y N Grease Trap Previous Pumping Date Grease Rendered Y , PIC's S' ure Prin t:#Seats Observed Frozen Dessert Machines: Outside Dining Y N Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N \� Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 6 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 3-202t12'-- Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15, Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) *- 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage* • Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 7-204.11 Sanitizers,Criteria-Chemicals* � 3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B)Returned Food and Reservice of Food* REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Was Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 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* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Anim^.i Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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. L16 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* 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* Eff ai-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* 4-703.1 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 1 3-201.15 Molluscan Shellfish from NSSP Listed _ Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in ca[er- Sources* 10 Proper,Adequate Handwashing Ratites-165°F 15 sec* ing,mobile food,temporary and residential C Game and Wild Mushrooms Approved By 3-401.11( )(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* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms*- _ 3-401.11(A)(I)(b) All Other PHFs-145°F 15 sec * 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 3-201.17 Game Animals 9 9 Requirements. 5 Receiving/Condition 2�01.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3 403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) * 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours.and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 - * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation'and Maintenance Within 4 Hours* 26. water,Plumbing and waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 - Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* f8-103.12 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. °p THE r° TOWN OF BARNSTABLE .� HEALTH INSPECTOR's Establishment Name: r,`��Lj�/(�_Date: Page: of, v` ti OFFICE HOURS I VW 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.9. �0� , - '� HYANNIS,MA 02601 _ - MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY �grFD MA'S° � 508-862-4644 FOOD EST BLISHMENT INSP TI N REPORT Name Dateqlff Tyne of ns ection ORRE11WME9Routine Address Risk oo Servi Re-' ection Level Previous Inspection Telephone Residential Kitchen Date: Y UN Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: n 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) ❑ s 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 _ p ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS If KM I >Q ❑ 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo Emergency Closure Voluntary Disposal Other:. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.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 non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have 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 F.C-7 590:008 9 viol 4 to non-critical vi IaY ns=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Ins is Print: 31.Dumpster screened from public view .. Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign ur Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N / Dumpster Screen? Y N i. 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°lerirperatures According to 1 590.003(A) [Demonstration nment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to - Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * Applicants 3-302.11(i1) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* -' Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 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 8 Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* _ 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.I 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* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg°"°e iiirz°°t 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 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* 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. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 11 Good Hygienic Practices practices should be debited under#29-Special 3-201.17 Game Animals* Yg 17 Reheating for Hot Holding 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g, g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* Lu Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Hem 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�02.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance WiUrin 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. 1 Poisonous or Toxic Materials I FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. TOWN OF BARNSTABLE 1/,�', HEALTH INSPECTOR'S Establishment Name: Date Page: of MU' OFFICE HOURS '� N BARN- sTAB�e.o) PUBLIC MAIN STREET DIVISION -r- 3:30-4:30 A.M. - - " - - 3:il M - .- P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS, MA 02601 0 MON.-FRI. No Reference R-Red.Item PLEASE PRINT CLEARLY. - '639• �0 � 508-862-4644 A'ED""A�a FOOD ESTAJ3,141SHMENT INSP ACTION REPORT Name Date a of Tvoe of Inspection g Routine ood Se Re-inspection Address Risk Previous Inspection Telephone Residential,Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary - Ilness Caterer neral omp Person in Charge(PIC) Time Bed&Breakfast Other Inspector Each violation checked requires'an explanation on the narrative page( )and a citation of specific provision(s)violated. n 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 560.009(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 Q rn e S O. _I ro ❑ 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 HS f ❑ 10.Proper Adequate PS Handwashing CONSUMER ADVISORY o // ❑ 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 within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no.more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils FC-4 590.005 B=One critical violation and less than 4non-critical violations 9 ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4,to 6 non-critical violations=B. 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- ritical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical. olations. If 1 critical refrigeration. 29.Special-Requirements (590.009) within 10 days of receipt of this order. viola' 8 non-critical violation C. . 30.Other DATE OF RE-INSPECTION: Insp tor' Signat re rint: 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. IN Vr 1 e� 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 L 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives*" 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*7-102.11 Common Name-Working Containers* 590.004(F) * 2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130'F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-,Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) 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* 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* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* 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* 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 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces o 88 f Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff-ii-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* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* } faces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3A01.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 8 � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PIlFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheati practices should be debited under#29-Special ng for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* * Blue Items 23-30) 3-202.15 Package Integrity g g 3 403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,.which do not relate to the Foodborne * 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated B) 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 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 1.008 HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements 1 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. I °FINE r TOWN OF BARNSTABLE HEALTH INSPECTOR-s Establishment Name: Date: Page:.of ° OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. 3:30 4:30 P.M.- BARWrABLE. ` 200 MAIN STREET Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified mAss �,, NON.-FRI.t639. HYANNIS,MA 02601 sos-asz�saa No Reference R Red Item PLEASE PRINT CLEARLY � �• gEOM FOOD ESTABLISHMENT INSPECTION REPORT Name Date (� Type of T s ion p tine Address Ris ection Level a Previous Inspection Telephone '11 dential Kitchen Date: Mobile Pre-operation Suspect Illness !r Owner HACCP Y/N Temporary Sus p Caterer General Complaint �- Person in Charge(PIG) Time Bed&Breakfast HACCP Other er S-�- Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. f Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ L Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ c FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands J_ ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS 01 F r Color ❑ 14.Approved 2.Reporting of Diseases by Food Employees and PIC ❑ ood o CoIo d IV ❑ 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 oz, �j ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling jf ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) / ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY �r y ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories K Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations -- Critical(C)violations marked must be corrected immediately. (blue&red items) �`�1 Corrective Action Required: Non-critical(N)violations must be corrected immediately or Overall Rating i l within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee estri tion/Exclusion ❑ Re-inspection cheduled ❑ Emergency Sump s C N Official Order for Correction:Based on an inspection today4fie items ❑ 90 ❑ Emergency Closure ❑ Voluntary Disposal Other: Embargo 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 (FC75)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t F is scored automaticallytion of rodents or insects,or lack of 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 9non-critical. If no critical water,sewage back-up,infestation ( )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 to 8n6n-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other PATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view a I/Y1.Q.s Iwo 0 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* F$ Cross-contamination F14 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 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15- Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* 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 Rrated or of Food 7-204.12 Chemicals for Washing Produce,Criteria* . HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g � ) Disposition of Adulterated or Contaminated - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g 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 ( ) liance 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* TIME/TEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* - Concentration and Hardness* 16 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective uuzoor 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 tr 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 g• P arY 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 - Cleari Condition-Hands and Arens* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock'Identification Present* - 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail - _ 3-201.17 Game Animals* 11 Good Hygienic Practices _. _ 17 Reheating for Hot Holding practices should be debited under#29-Special -.2�01.11 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* 3AD3.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS It IONS 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 Foodborne 12 Prevention of Contamination from Hands 3-403.11 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°17 Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-50L14(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. 1 Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 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. �p INE r TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Page:. of o OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30"A.M. BAFt ABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS, p MON.-FRI. ,63 P+a�eO HYANNIS,MA 02601 s0s-8s2 as44 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTI N REPORT Name Date ' ( 1l Pe of T section r' ,Aller outine Address;gek Risk c"on Lever a Previous Inspection Telephon ' ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness G ° 1. Caterer General Complaint 1 Person in Charge(PIC) Time Bed&Breakfast HACCP t Other In: 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) ❑ 0 Cw-k- 13 r- W Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ 4N ( I 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 i ❑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-y within 90 days as determined by the Board of Health. the' ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today, Items Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Emergency Closure ❑ Voluntary Disposal Other: ❑ 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 6=One critical violation and less than 4nori-critical violations 9 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 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 (FC77)(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. violation,4 to 8rion-critical violations 29.Special Requirements (590.009) within 10 days of receipt of this order. =C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Du:�y r screened from public view t' 1 ��,� •�� Permit Posted? Q4.t N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatur Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen o Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Dudes 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods_Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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 Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg cnvc 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 r f Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 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* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11 C Game and Wlld Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* ( )(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices _ Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the 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* FIg Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140'F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient, 24. Food and Food Protection FC-3 .004 3-40211 Parasite Destruction* * 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* 2 . Water,Plumbing and Waste FC-5 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Dry 6 .006 Drying Devices 2 . Physical Facility FC-5 .00 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 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. eTHE T TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page; of o �t OFFICE HOURS ~° PUBLIC HEALTH DIVISION 8:00-9s0A.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 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEA Y , �A ,639.6 0 - 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name 44 Dae of jyRe of Inspection era jv ions Routine Address Risk Foodice Re-inspection `Level RetaTi'enl'ial Previous Inspection Telephone Resi Kitchen Date: •� Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint HACCP Time Bed&Breakfast �. Person in Charge(PIC) Other In: ItA l Inspector Out: LOLAII 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 f ❑ 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 YJ ❑ 5.Receiving/Condition ❑ 17.Reheating r ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑.7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) �Jl' ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ' ❑ 10.Pro erAde uate Handwashin CONSUMER ADVISORY P q 9 , 11.Good Hygienic Practices 22.Posting of Consumer Advisories ❑ Y9 ❑ 9 - Violations Related to Good Retail Practices(Blue Items Total Number of Critical Violations v Critical(C)violations marked must be corrected immediately. (blue&red items) 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,ie, ms ❑ 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 )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-criticalati violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation;4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view r Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N 90 #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*. 6 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.1](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 15 590.004(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* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage*_ Applicants* 3-302.11(A) Food Protection* 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 3-501.19 Time as a Public Health Control* 3-302.15 Washing Fruits and Vegetables Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* (590.004 11) Variance.Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and AdulteReserrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition ofAduIterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual 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 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 Wazewashing-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 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 v 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* :-10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Mid 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. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail _ _ _ 3-401.11( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* C Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.1 Package Integrity 3-403.11( ) y 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodbome 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 [6-301.1 03.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 3-402.11 Parasite Destruction* 04.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 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/ 1 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7HACCP Plans 301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 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. 4. y �p 7NE row TOWN OF BARNSTABLE.. ... HEALTH INSPECTOR'S Establishment Name: Date: Page: of q OFFICE HOURS ARN E.O` PUBLIC 0 HEALTH A STREET SION - - 8:00 9:30A.M. - - - 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified Me v: `0� HYANNIS,MA 02601 MON.-FRi. No Reference R-Red-Item PLEASE PRINT CLEARLY 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT. Name / Date a of T ins c ion " v to s outine Address Risk spection Level etail Previous Inspection Telephone Idential Kitchen Date: ' s Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint 57 Person in Charge(PIC) Time Bed 8 Breakfast HACCP oe9 In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. c� Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM.CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time Asa 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 El 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 6 non-critical violations if no critical violations observed,4 too von-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 violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials .(FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 non-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.Dumpster screened from public view ' � ( I/�. (r o 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.) r j . FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41^F/45°F 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* g7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* P g Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130^F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 . Washing Fruits and Vegetables ,�7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590,004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) ! Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B.)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 17.206.12 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 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 E s-Immediate Service 145F 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* EB-r;ve;nrzooi 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* 3AOl.l1(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* 1 o 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. 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )(b) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding 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 foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140`17 to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within.4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made-from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction*Creation an 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 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. °p THE rok, TOWN OF BARNSTABLE _ HEALTH INSPECTOR'S Establishment Name: Date,• - Page:_ of q 'OFFICE HOURS AR E PUBLIC 2 0HEALTH NSTREET SION 8:00`-9:30A.M. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified mass. g MON.-FRI. NO Reference: R-Red Item PLEASE PRINT CLEARLY te3q. �• HYANNIS,MA 02601 508-862-4644 N1P'p FOOD ESTABLISHMENT INSPECTION REPORT Name Dat Type of T Inspection rp &ti Address 11 Risk I spection Level ai Previous Inspection Telephone sidential 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 i 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/ P ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures �' ❑5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total'Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately.or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection todWetems checked indicate violations of 105 CMR 590.000/Federal Food Code. El Embargo ❑ Emergency Closure ❑ Voluntary Disposal [],Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.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: 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 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 8non-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: Inspector's Signature Print: 31.Dumpster screened from public view Jam't'l . ra Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N Cam`( #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 4a,_� Violations related to Foodborne-Iliness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) ti FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 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 Identifying Information-Original Containers Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each * 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-20 Require Reporting by Food Employees and Contamination from the Environment 7-101.11 Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130°F* * .11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003 F Responsibility of A Food Employee or An 7-202.11 Restriction-Presence and Use* * O P y3-302.15. Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* - Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003 D Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* ( ) 3-306.14(A)(B)Returned Food and Reservice of Food* REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Disposition ofAdulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* 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* 4-501.1 1 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* _ 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. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(l)(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 cr;ve inrzom 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency r f ces Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4 703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009 A D m cater- Chemical ( )-( ) Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 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.l l 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 929-Special 2-401.11 -- Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition - - g, 8 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 3-202.15 Package Integrity* 3-301,12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23.30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-lOLll 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 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70*F to 41°F/45*F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 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. oF; r TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date: Page:, of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. % BABNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ,p39, `0$ HYANNIS,MA 02601 nnoN.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY rF. 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT -G. Name Date ` ! e of T ns ctio _ 6 outine Address Risk ervi pection s " Level a Previous Inspection Telephone ential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Y 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 y 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 41, 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 P ECTION FROM CONTAMINATION ❑20.Time As a Public Health Control 8 eparation/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, 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)(596.004) 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 6von-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 la 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,7 to a'non-critical iolat violations. If 1 critical refrigeration. 29.Special.Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N '� ��I r. v- - •- -fir ,-.-�.,.��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.) t 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 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods 11 for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 _ _ Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11 A 2 Raw Animal Foods Separated from Each 590.004(F) ( )( ) P - 111 n'7 10 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 Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*. Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* Requirements * 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Re q 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Resumed Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of 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* eb crave 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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g �' S90.009(A)-(D) Violations of Section 590.00.9(A)-(D)in cater- 10 Sources* 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* Ratites-165°F 15 sec*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-145'17 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* 3A03.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave.-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity y Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention of Contamination from Hands 3-403.11 E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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 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- 6 5 .00 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 2 . Physical Facility FC-5 .00 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria*_. 8-103.12 1 Conformance with Approved Procedures* S: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. 1 1 �p 1r _ �a No. -- Fee----- - BOARD OF HEALTH TOWN OF BARNSTABLE j 2pplitationfforlVell Con5tructiotupprmit Application is hereby made for a permit to Construct Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel - Tom° t__� o �°�cn��_— — ►fr 3 . ^_LQ��,t 1` /`^ P, _—_ Owner Address — Installer — Driller �— Address Type of Building Dwelling —-- --—---------- Other - Type of Building—= --____ No. of Persons------_________---___ Capacity— ------__--_--___-- Purpose Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Ton of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Ce ificate of Compliance has been issued by the Board of Health. Signed date Application Approved By date Application Disapproved for the following reasons: date Permit No. 10 __ Issued-- - -�� — —_ date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif hate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (—�, Altered ( ), or Repaired ( ) by / /� instai;cr R —— — —has been installed in accordance with the provisions of the Town of Barnstable Board of HeAth_'rivate Well Protection {��)- Regulation as described in the application for Well Construction Permit No. f ated---- — THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector ................ No.------------------ AA Fee----- =------------ BOARD OF HEALTH TOWN OF BARNSTABLE � T Application for lVell Con5tructionperntit Application is hereby made fo a permit to Construct ( K, Alter ( ), or Repair ( )an individual Well at: -- Location — Address -- Assessors Map and Parcel — Owner— f Address — 1 1J l Installer — Driller ---T Address Type of Building Dwelling ---—--- ----- ' Other - Type of Building-- _—_ No. of Persons- Capacity- Agreement: _ The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until 7Ce ific�te of Compliance has been issued by the Board of Health.� 'l% S b�w- Signed -- - - date � Application Approved By -- —_-___- date Application Disapproved for the following reasons: date Permit No. O"- D — Issued date ----------------• BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate (Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ("J, Altered ( ), or Repaired,( ) - by Inst`atl —' S�otp S l o� "• ,. 0$ Co�r►r� at has been installed in accordance with the provisions of the Town of Barnstable Board of!halt rivate Well Protection k..� Regulation as described in the application for Well Construction Permit No. --"Dated-- -THE,ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- - - Inspector—__- ------- —----- -------- --__- ,-_.___ _----- ----- --------_.-----------.._-- BOARD OF HEALTH TOWN OF BARNSTABLE Veil Construct ion permit � 20-5t)'_- No. Fee--------- Permission is hereby granted .Q A SCo" to Construct ( '�, Alter.( ), or Repair ( ) an Individual Well at: No. S�"rF r- .� rya /' J$ • La +��_ --------- - - - - - - - Street as shown ofn/th l�a� t_ a1We�Il)Construction Permit ' No.- N -x / Dated - - ---- - --------------­------- lth DATE J G7 �, Board of Hea 2-26-202 2:29PM FROM GRIFFITH VARY INC. 503 295 0003 p. 1 Consulting Engineers 12 Kendrick Road 4Z;amham,MA 02571 (508)295-0050 Fax: (508)295-0003 FAQ TMNSMITTAL SHEET TO: MY. o� J FROM: V� �,�{�►"� COMPANY DATE: FAX#:_ ( - Sob •710 • 40 3 O TOTAL#OF PAGES INCLUDING RE: V F'p'" f" Sg o°` COVER PAGE: Cofi � L.a�.�ih TL f G.L, f t"I'e,se &A,(te 4 14 r- Cosw, p -o('P' oa ►w Tlq�s t.nl }�ho�', URGENT FOR REVIEW PLEASE COMMENT PLEASE REPLY 71,o a 7-r 3o G t� `G-Gb-Lr7G :G`JF'M r KUM UF'C 1 r r I I H VAKY IN U. blOd 2yb OULI-5 P. 2 j I i U m U i a I a a» OUTLET INV.- 95.50' 1 F_C.O. ( _ DISCONNECT EXISTING WASTE PIPING FROM i 3» `i--1 i THIS EXISTING SINK /4»,� \ AND CAP EXISTING r C-0. 4 ..i �` .�j 1 WASTE UNE AT FLOOR- -- w CONNECT THIS SINKS I WASTE uN To A NEW i C.O. j I I i -� Y HORIZONTAL LINE IN i i L I VOID BEHIND SINKS. i I I (INSTALL AS HIGH INSTALL NEW AS POSSIBLE) EXISTING HAIR 1 WASTE PIPING WASH SINKS I ' TIGHT TO WALL I ; TO REMAIN I l FINISH FLOOR j I I F_'I_EVATION 100.00' PROVIDE NEW SIGN OVER RE-PIPED j SINK TO READ AS FOLLOWS: i DYE & PERMANENT I� RINSE SINK 1 i i` } I i I i - Griffith & vary, inc. UPPER CUT SALON _ COTUIT LANDING CONSULTING ENGINEERS C o T U T Iv!A 12 KENDRICK ROM TEL ' HAIR WASH SINKS PIPING PLAN FAX: 15(*) 293-OM sc�u�: . />s.-,.-o DAlL ,a.I e-01 WA"M er CHECK RV_ P--S K—I w.Jw J.E.Z. OAI Wr N I ;rl J o. Fee r THE`COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migpogal bpgtem Congtruction Permit Application for a Permit to Construct( , )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components i Location Address or Lot No. 3300 Falmouth RoadL$ Owner's Name,Address and Tel.No. 617-770-8706 P�1•M " Assessor'sMap/Parcel Stop & Shop Supermarket Company col P. 0. Box 1942, Boston, MA 02105 S f3- t Ins r' Name,Ad; and Tel.Ng. Designer's Name,Address and Tel.No.7$1-924-1770 co, Vanasse Hangen Brustlin, Inc. 7. ©: ?)�� �yr A 101 Walnut St. , Waltham, MA 02471 Type of Building'"-'"'o Dwelling No.of Bedrooms N/A Lot Size 2,062 9130 sq.ft. Garbage Grinder( ) Other 'lope of Building Retail No.of Persons N/A —Showers( ) Cafeteria( ) Other Fixtures Prof. Offices, Restaurant, Retail and. Supermarket Design Flow 21,600 gallons per day. Calculated daily flow 10,050 gallons. Plan Date 9/11/01 Number of sheets 26 Revision Date None Title Waste Water Collection and Treatment Facility Size of Septic Tank N/A Type of S.A.S. Leaching Area: Pressure Dose Description of Soil: Sand/Gravel 6rto4e r-to • yoQDDESIGNING ENGINEER MUST fa SUPERVISE Nature of Repairs or Alterations(Answer when applicable) INSTALLATION AND CERTIFY IN WRIT H__ S STEM WAS INSTALLED IN STRICT TO PLAN. Date last inspected: Agreement: The undersigned agrees to ens the cons ,on and maintenance the afore described on-site sewage disposal system in accordance with the provisions o tle 5 of th 7vireonrnta Code a d of to place the system in operation until a Certifi- cate of Compliance has been is this Boaz l -®• Signe Date Application Approved by Aj z Date Application Disapproved Porthe following r s ns f Permit No. Date Issued t► M No. �t% E - �,.. { ` f € 1�t[� Fee � .c ,'�Y. !F i f 311.1►-�,'..� � '..Ft IX �1 S�5'^^.*p ', .` . ?� THE'COMMONWEALTH bfrfM ►SSACHUSETTS s Entered iWcomputer: �_ kr. '- �, - _ s Yes ' P�J:_ LIC HEALTH DIVISION•-;TOWN OF BARNSTABLE,.�MASSACHUSETTS' , - t Zipprication for �Digpoo'al- pgten� Congtruction Verntit Application for a Permit•to Construct( )Repair( )�Up )Abandon( ) El Complete System El Individual Components �- �� �'� Location Address or Lot No. OO Falmouth Ao3 Owner's Name,Address and Tel.No. 617-770-8706 A M molts SStop & Shop'Supermarket„Compan Assessor's Map/Parcel $/�4 y r' � ; P. 0. .Box 1942, Boston, :MA 02105 _ Installer',s Name,Addres ,and Tel.No, Designer's Name,Address and Tel.No. 7$y1-924-1770 L,16^1 � N� r Vanis'se Han en Srus tlin3, Inc. ,�' �; o, q /�y i 101 Walnut St._., Waltham, MA 02471 Type of Buudin : `" ri .,�._:...b N/4 Lot Size 2,062,130s ft. Garbage Grinder Dwelling No.of Bedrooms q. g ( ) __ -Other Type of Building Retail. No.of Persons NA Showers( ) Cafeteria( ) - .kOtherFixtures Prof. Offices,.r Restaurant; Retail,and,,Supermarket : Design-Flow1,600 gallons per day. Calculated w_ daily flow, 28;050 D gallons. - Plan Date 9 11/01 Number of sheets 26 r . kIvy Revision Date None Title Waste Water Collectionaand Treatment Facility Size of Septic Tank N/A Type of S.A.S. Leaching Area: Pressure Dose , Description of Soil - Sand/Gravel �--- 6r("Jr 000 G Nature of Repairs or Alterations,(Answer when applicable) DESIGNING ENGINEER MUST SUPERVISE ± INSTALLATION AND CERTIFY IN WRITING fft SYSTEM WAS INSTALLEU IN STRICT 10 PLAN. Date last.inspected: Agreement: The undersigned agrees to ens a the cons con and maintenance the afore described on-site sewage disposal system 1....-- in accordance with the pro4iu itle 5 of th E iron enta Code a d of to place the system in operation until a Certifi- cate of Compliance has be this Boar, o Hea + Signer . Date -0? Application Approved by V ��/ l�- ` O Date Application Disapproved for the following reasons " I fir rl�A Permit No- .,Date Issued THE COMMONWEALTH OF MASSACHUSETTS - B�ARNSTABLE, MASSACHUS=�—��� a2 r%P ar✓ : R�do, .j 'DESIGNING ENGINEER MUST SUPS-`.'ISE certificate of �Corit YtaQ��TALLATION AND CERTIFY IN b'/' "` G p "CAE SYSTEM WAS INSTALLED IN z_,.�;LT THIS IS TO CERTIFY, that the On-site Sewage Disposal System ConstpGW((DANr&fT,*fUN. )Upgraded( ) Ab d ed )by "a, SHD u V has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. )6)!-7 t/ dated 12 1 1/2 /41 Installer Designer l , The issuance of this permit shall not be construed as a guarantee that the systetwill�fu ction as esigned. Date a S�� Inspector i — a ...... —————— ————— — — Fee THE COMMONWT � PERV ��WRITIIE PUBLIC HEALTH DIVISIOI Hd%ARN_$ 4 TWLQ�Sj�►�g ETTS ACCORD,`,::3E TO PLAN. �Digogar Pr5tem Construction Permit Permission is hereby g truY, )R O , / don( Akkl�_ System located at r ° N and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons 1tion teelompleted.within three years of the date of t Date: - ! Approved by / ' t No....&n... � Fes$.. � .,................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ApplirFa#ion for Disposal Works Tomitxn.rtiun Famit Application is hereby made for a Permit to Construct ( ) or Repair (t-�j an Individual Sewage Disposal System at: ........... F?7vS..�.......zi�N;�IIJCG 9>L------ ST�.NS_..�V1PLL - -- .............. ....- ......... .............. ..._ Location-Address or Lot No. Owner Address 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 44 Other fixtures -----•-------------•---------------•----•----•---- -- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth....._.......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--__-_.-__.---_---.-___- 9 1 ........................-.................................................................................................................................... 0 Description of Soil...............................................................................--------------------------------------...------•--------------------------••-•---------- x U •--•--•-•-••-•---•••••----------•---••--•-•-•--•........-•--•••••-----•----•-------••--••-.....•••••--------•-•--••-•••••-•--•----...-•-•-•••--•--•------------••••--.....-••--•--•••---••----•-•-...... VW ---••------•----------------•---•--••••••----------••-••-•••-•--•--••••---••••--••--•-•...-------•------------ W_,4to...........:................................................. Nature of Repairs or Alterations—Answer when ....... le...`.v—o_N Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Env' ental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com lianc been ' ued by the board of health. Signed .............................. ---- - ------------- ..............5 $ ^g -------- Date Application Approved By --------------- J <>c-.,�.�a� -----........................... .......-......................... �`�-".3d.....?/------ Da e Application Disapproved for the ollowing reasons: ........... ----------------------------------------------------------------------------------- ------------------..................................................................................................----------------------- .......................................................... ------.--- ------------------------ Daze PermitNo. -------9/.=-----2-3jQ----------------------- Issued ...................------------------------------------ ------ Date :.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrurtion rumi# Application is hereby made for a Permit to Construct ( ) or Repair (V)r an Individual Sewage Disposal System at: j- CDT,(v,Pz r !_H i.j >i K.-)G 3->c.lq Z f-1 - - - `)-n fa Q S?-o NS �n�L .... ...- ....---•- Location-Address — or Lot No. ....................................... .......... •---g`-�'-6,._.o�...�'�:-.. - ................... Owner Address a --------------------------------------------------. .-------•--- ------•-------•----•-----•-•----•------------•--.... Installer Address d Type of Building Size Lot--------------------•-•-----Sq. feet U Dwelling—No. of Bedrooms_---------------------------------------..Expansion Attic ( ) Garbage Grinder ( ) t aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow............................................gallons per person per,day. Total daily flow............................................gallons. 1:4 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 ( ) 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........................ O Description of Soil.................,........................... U .....................-----------------•--•---------------•-•-----•-•----------------------------•-----•----------------•--••---------------------------.....------------------------•----•-------------- ----------------------------------------==------•--•-•--•---......-----•--•---•-•---------------••-----•-•--•------- '-C.O-------•-......------•------•-----•------••= U Nature of Repairs r'Alterations—Answer when applicable.__ .___/000-••� `'�' �-c�- c K{Sl'r N G Agreement: - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Enviren.mental Code'—The undersigned further agrees not to place the system-in operation until a�ertificate of Com{"Iianc �een ids ued by the board of health. Signed .............................--------v--------------. ----------------------------------------�K- S-�a-g--��-�------- 1 k Dare Y Application Approved B ' _........ �. F' cn. Dare Application Disapproved for theP01100-w—ing reasons: = S _r ....... Date ' PermitNo. ........y/--'------ .%? ------------------ Issued ........................------... -± Date t' 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Terttfira e of CZnmytianxe - THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed g p y ( ) or Repaired by '` _;3 C,9-ti.c .................................... ------------------••---•-•----------- ....................................................... Installer atCO U !_/9.IV�f. ?. .- ----------------------------------•---------........................................................................................ .. has been installed in accordance with the provisions of TITLE 5 of The State Environmer-tal Code as described in the application for Disposal Works Construction Permit No. .. : , -- ... f �. '-- - -- - --••--•----- dated ------------------•-•------ ------------------ - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED�AS AGUARANTEE THAT THE G,fV SYSTEM WILL FUNCTI SA'1SFFX41:TORY. DATE. ................................ Inspector --------------------.....--•---------•-•--.......------------------------------.------.-------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �} TOWN OF BARNSTABLE •No....,7�..- � FEE..�d•r ............ Disposal Works Tonstrudion f rrmi# Permission is hereby granted............. ..... N.�''�?...._ to Construct ) or Repair ( 1.--an Individual Sewage Disposal System at No............ _. . G.....PLA:X A PT -•-Z ••...•- ' . . . -.. ......._ Street as shown on the application for Disposal Works Construction Permit No.7,l..' 1�. Dated.......................................... ................................................ •� oard of Health DATE.................. •- ?2."��.............. .............. FORM 3830E HOBBS 6 WARREN.INC..PUBLISHERS r t �T.. r r N6?8 3 `LS_ _ :�- Fizz........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............Town................OF........Bcarnstable .. . .................................................... Appliratinn for Disposal Works Tonotrurtion VPrmit Application is hereby made for a Permit to Construct ( x) or Repair ( ) an Individual Sewage Disposal System at: a�'1 Fdlmouth•_Rd. (Rt.....28)••-.C.atuit....••••••.38 .314 3836 13 .................................................................._..._._.._...... Location-Address - - . ••---••••---••--••••--••----•---------•••-or Lot No. ........lJ.:..__�eaY4.................................................: .................................................... pwner Address .wa . ................................................. Installer Address 14.61 Type of Building Size Lot.... XaCZ eS .. Dwelling— No. of Bedroorr�..... .... ..........Expansion Attic ( ) Garbage Grinder ( ) a tte Ta l� C14 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ............................ W Design Flow............................................gallons per person per day. Total daily flow...1.t.17.3..........................gallons. WSeptic Tank—Liquid"capacit?2000..gallons Length.....12..... Width...6�.Ta.... Diameter................ Depth... ..'........ x Disposal Trench— No..................... Width.................... Total Length.....................Total leaching area.. .....----------sq. ft. 3 Seepage Pit No....2.............. Diameter.......12........ Depth below inlet.....k........... Total leaching area6V2.........sq. ft. Z Other Distribution box ( ) Dosing tank ) // aPercolation Test Results Performed by.. .e.�sW .tatey..•CO•.•,•-_InC•.--•.•-.••• Date......1/241.83............. a Test Pit No. I......2.......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........................ a -------------•-•---...................--••----.---.---.----................................................................................................. Descriptionof Soil...... .Q-1.'........ ...l..&..Subsoil............................................................................0.......... 1-12-----clean •••medium sand v ------------------------------------- ------........... .. ............... ... ..........------------------------ ------..-------- w ............................................................................................-----•......•----•-•---.... ---........................................••---.........-...----•----........... UNature of Repairs or Alterations—Answer when applicable........................................................................................0...... ...-....-...............................................................•..............0............0...............................................---•-----------..................................... 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. Silr . -- .............................................. ... / .•��1�.- Date emn ApplicationApproved By.............. .................. .... ....................... . ...... ..............0......................... Date Application Disapproved for the following reasons:.......... ... ..- -------•-- ................................................._ ............................................................................................... ....._,.........---..--...........................................................Date.............. PermitNo................................................. Issued.............------.--.---..........................--- ^ Date � 9 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...•---....T.Qwn..................OF......Barnstable---------------------------------------------------- Appliration for 13iiposal Works Taustrur#tun 1hrutit Application is hereby made for a Permit to Const�v (X ) or Repair ( ) an Individual Sewage Disposal System at: Filmouth Ed. (Rt. 2.8) Cotuit 3� �Z'� jg36 13 ................---..---.................................: ----------•---••----•-•-• --•-•------...............----•••-••-------------•.........------......................---------•• _►�_Location•Address ________________________________or Lot No. �......... .......,A' liGew�e�. __________-..--•---..-..._•----•-------•---------•------- _ .............•--------••....._................ Owner Address Installer Address 14.61 d Type of Building Size Lot..........................� XaCreS U Dwelling—No. of Bedrooms. Expansion Attic ( ) Garbage Grinder ( ) ~] r,ptail------------------------ p,, Other—Type of Building ............................ No, of persons........_................... Showers ( ) — Cafeteria ( ) G" Other fixtures ------------------------•------• - d ------------------ ••_.. y.....--------...........-------------------- W Design Flow............................................gallons per person per day. Total ailx flow-- .!.�7............•............._....pAlons. WSeptic Tank—Liquid capacit �....gallons Length.__..12...... Width._...*2..... Diameter................ Depth._- ............ x Disposal Trench 2No. .................... Width.,..__..........._. Total Length................. Total leaching area. __...._._..sq. ft. 11 Seepage Pit No..................... Diameter.._................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin t nk 11 F t 4JR Utley Co. , Inc 1/24/83 a Percolation Test Result Performed bY-•-•-.---...... e------•------•--....••...................'....--.... 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........................ p�V...--topsoil...Y'-sul6soll----------- ......•------•---•------...------------------------•---------- D Description of Soil.............. r , -----------------------------------• x 1-1Z. ...cleari; me3i:um..siihd-------------- = v ------------------•-------------- •------- .------ ••--•------------- .-..----------- •----------------------------------------- • _"I,--------------------...-..---•--•-••-•---•-----.....-•--- •- U�l ....................................................................................................................................................................................................... Nature of Repairs or Alterations—Answer when applicable...............................:..:.:.............................. .......................... :. ----------•--------------.................................---..-------------------------------------------------------------•............ -------------------......::.--------••....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 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. Si ............................................... - ate Application Approved BY ....................................... .................. ' Date Application Disapproved for the following reasons:...... V............ ,.................................................... - Date PermitNo......................................................... Issued-....................................................... + Dau fi THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town ;x•m- Barnstable .........................OF...............;..................................................................... �� (9rdifiratr of (foutpliattrr THIAJI.S T,,P� �'IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...... p' � ......... .......... ......................••-•--•- ....-----------..........------._...----------------------------..........------............... ..+�'�./�7� � �,�.,� Installeerr at................................•-•-----•-----.......-----............-----------------------------...._ has been installed in accordance with the provisions of T j� The State Sanitary Code as described in the application for Disposal Works Construction Permit No...................•..................... dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE --------------------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ...............................OF... ..........................-_ ............................................... No......................... FEE.. .................... itoon #rtiun rruti# Permissionshereby granted...................... --------------------•--.---•-------•----------------••--•-••---•----------......-•-•----............................... to Constr it 1du 1 wa o S ./ at No...... w Street as shown on the application for Disposal Works Constructi ermit o.... ........Board of Health Dated.......................................... i DATE.........................................-r,,f_`�� Ur� .......-------- ...........................!� _ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 'Q No...8A...;7 THE COMMONWEALTH OF MASSAC14ust-It' s BOARD OF HEALTH TOWn ....... OF ...Barnstable..... _................................................. Appliration -for MoVinal Works Tonstrurtion Vrrmit Application is hereby made for a Permit to Construct ( X) or Repair an Individual Sewage Disposal System at: Route 28, Falmouth Road Lot 2 ........................................................­--------------------------------- .............................................................................................. cotUit LandingLocatio'�r(�:Mt!sVerit-ure Box 920, Cotuit, ngsd�-,husetts ................................................................................................. ------- -------- -------".......................................... Owner ddress :4 ....... .......... --------- ----------------------------------------------- --------- --------------------------------- Installer Address Ty-p?eof Building Size Lot 7.54.7..Ar Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) 04 Other—Type of Building __qh1PP9_t...q�_t No. of persons....._...._................ Showers Cafeteria ( ) Otherfixtures ---------------------------------------------------------------- ................................................................................... Design Flow............................................gallons per person per day. Total daily flow....3.9.60...............................gallon.N/dL_,17 Septic T.ink—Liquid capacit'v.-70-00.gallons Length J:T�'.:7�Q" Widt iameter................ Depth.8!-111' Disposal Trench—No. .......... Width.................... Total Lengt eachin area--------------------sq. ft. *6 Diameter.J4' 6" Seepage Pit No... .....pit- .............. Depth below ieach g area..................sal. it. Z Other Distribution box (X ) Dosing tank Percolation Test Results Performed by.....................E....... il 27, 1981 e....APK-------------.......... Test Pit No. I���ilnutes per inch Depth of Te. .... 0-4 to round water_.NPPP........... EncOuntered �14 Test Pit No. 2................minutes per inch Depth of Te t .ground water 13;- .................... .................................... ... ..... ................................................... Description of Soo shall stone 0 Medium and s ...... ........ ....... U ............ .................................................................................................................................................................................. See sheet 4 of 5 for test pit information and leaching pit details .....................................................pit ..pit --------­----------------- Nature of Repairs or Alterations—Answer when applicable.............................................................................................. ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t# hoard of health. 'A igned..e -- .� ...... ---- ------------------ ------- ... .......... ....... ............ Da Application Approved . .. ......... Date Application Disapproved for the follouring reasons:........... ................................................................................................. .................................................................................................................................................................­...................................... Date PermitNo--------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........ka .. ... .....OF_1 ........................................ . ........ Trrtffiratr of Tompliatirr _y, 7- THIS IS TO CER7*11' That the Ind' idual Sewage.Disposal System constructed (I or Repaired by................................................................he I-n-d• . .. .­:g ........... Installer at......6:� ..... .. ......as-------------- ---.............................................. ------------ has been installed in "'i with the provisions of Art* le XI of The State Sanitary Code as described in the ­.......... 7 application for Disposal Works Construction Permit No_......17_�:>y_f............ dated,........... .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THEE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... .................................................... Inspector.------ ........................................................... No.. ..4 _��'..�� Fxx.......... tr .► • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town ......... OF....B.amstable...... ................................................... Applirtttion -for Disposal Works Tonstrurtion Vrrmit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: Route 28, Fa]mouth Road Lot 2 ....... ------••--•-••---....._--.•-g_ ---.......-...................................... -•--...... ---•------••--••-•-•••'-••'----••--'---•----••--....-•-••----'..._.•--'--....----•••. nrn dd��s - I,ot rr o. Cotuit Tanr3i n '-'c-�Oi r&Ms Venture Box 920, Cotuit, Massachusetts --------•• -- ------.--•------•--------------•----•------------ ............................................---••'-------••-•-.............................. Address • Owner W .... .� Installer Address d Type of Building Size Lot.7...54.7_..Ac_......XWW U Dwelling—No. of Bedrooms...................... ...._Expansion Attic ( ) Garbage Grinder ( ) per., Other—Type of Building ._PhTPgz._Ctr, No. of persons._------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures _....---•---`----••------------ - - Q ----.. W Design Flow...................•. .._ ..._............gallons per person �r day. Total daily tflow_;_.3960-__.--•.--_.._..........._____.gallons/da_- Q4 Septic Tank—Liquid capacity__70.0.0.gallons Length.1�...._Q.. Widt lameter................ Deptli.8..-11 . W Disposal Trench—No--------------------- Width.................... Total Lengt �_ N.ff_/ .1 :.leachin area....................sq. ft. :V. Seepage Pit No..*6..P?1§.. Diameter._l4'-6" _ Depth below i ',jeach gare:t..................sq. fl. Other Distribution box (X) Dosing tankRbe ( ) = Percolation Test Results. Performed by..--_----_._-- E• � _ -'. ril 27,--1981 Test Pit No. 1�iinutes per inch Depth of Te. s. to*round water.-NOne-----_---. Test Pit No. 2................minutes per inch Depth of Te t .'-.i&i ground waterEncOuntered P P c `or- .......................................... - ....--••----- Medium sand-and small stone Description of Soil ti.......-..:<_ C U * See sheet .4 of 5 for test it information and leachin it details W ------------------ -------••- <----------------- ------------------.....•••-----•-----•-----------....----•--•-•••--------•--•----•.•-..-•••------•-••---•---._...--j----------- ------ UNature of Repairs or Alterations—Answer when applicable------------------------------------------------.-----------------.-----------.-- ---- -•-------------•----....._._....._..........------••----•-----... ------••-•--------------••--'...--•----••---.....-•----•-•-•---••----•-------.......-•---•---•------••-- ------------•- ............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. �)at A lication A roved B t.�i _: /C �'X ---- PP PP y------- --- -=---------------- --------------- /r r Date Application Disapproved for the following reasons:-----•---------------------------------•------••---------=----•-•----------------------------•------------------ .------•-.---•-•----------•------••------•-•---•--•--------------------------------•--------------------•.-----•--•-•--------••-•-.-----••-------•--------------•-.................................... A Date PermitNo........................................ ••---••----'---• Issued--------•------•----- ----------------•-•-•-.....•----- Date THE COMMONWEALTH OF MASSACHUSETTS . .5 E BOARDS OF4; HEALTH .........�.qw�' +- ......... .....OF. y. ................ti.............. 1 Trrtif irttte of (lomplitture THIS IS TO CERTIFY, That the Ind' idual Sewage JDisposal System constructed (;/) or Repaired ( ) by........................................................................... ------ nst aller I -----------.-...........................-............ .........-................ p GInst -- --••-----.-- has heen installed in accordance with the provisions of A�r 1d XI of The State Sanitary Code as described in the CJ�w application for Disposal Works Construction Permit No---------- ' .............. dated....................................._........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............•-••---•----------••- •--------------•••......-•-•-•---....-•------ Inspectory.o59_.,rA..lr...-/----- ................................. THE COMMONWEALTH OF MASSACHUSETTS v BOARD O HEALTH 8� � .....:. .....OF ...... .. .......... ..... .. ...... FEE: . .�'"' _ No......................... . . .... Dinvusttl Nor s Tonst urtinn Vrrmit PermtssioI hereby granted................... .... ................. .Q.l.. ... •. ... .......--------- ----.... ----............... ................. to Cons _ ) o I: �. ( ) a� Individ Sew a Disposal System atNo.. —................. ......._.......-•--•-•. .. R. ., / .-....._... t Street as shown on the application for Disposal Works Construction Permit No.... T _ llated...-......� --/ :. ..._ uard of Health DATE.........,.... .."'.... 0... - ------------------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Pt ffog`,`f�//'1/ C ffl6,,, � h I - "- FRI�Ip``� �qq SE SENVE � :fr...y,,."row wun$ dZ a �mr s . Exclusive Featul"es. Delhaize Y, ➢ Stainless steel body ➢ Heavy 14 gauge 304 Stainless steel countertop ➢ Frameless tempered glass sneezeguard ➢ Clear end draft control panels ➢ Wet or dry food well operation } ➢ Infinite & individual control on top&bottom heat of each well € ➢ Casters andP P _ lu -in operation allow unit to be used and moved Giant g anywhere in your store ➢ Custom sign package in color and text of your choice National Chain Single Unit Pricing 6' I" l IN MHFC7344-DA Base Price—stainless steel body, 14 gauge $ 7,180 l/l 304 stainless steel countertop, locking casters, cord&cap Crating $200 l l Steel Surcharge i$I� 6� I Options: t/l • Single phase breaker panel—BPI Included Custom 48"power cord with locking Pin& Included l Sleeve plug • Top feed electric supply for ceiling drop Included connection • Mating Pin&Sleeve connector for 1 phase $ 1.80 • Food Pans and Utensil Items Quoted as Required Specifications: • 12"x 20"Pan Openings 5 Steel surcharge is a straight pass-through cost and is, Atlantic Food Bars reserves the right to change valid for orders placed before 911118 and is subject to • specifications without notice increase or decrease on the first of every month, based-upon steel pricefluctuations and the effects of , tariffs proposed_and imposed; Sales/Use Tax Not Included g All orders subject to a 50%cancellation fee Pricing is FOB factory and valid for 30 days ALL MECHANICAL CONNECTIONS TO BE MADE BY 0THERS front August 7, 2018 5—pan Hot Food �,d'�10' � � � MASTER APPROVAL Ahold DIN WINGS IP #MHFC7344-ECB-UO-DA 1 73" L x 44" D x 56" H ... Delhaize Approval — Complete All Sections III Colors: Shown with top feed � Body: Stainless Steel connection box, cord Countertop: Stainless Steel and plug ® Electric: Voltage: 120/208V Phase: 1 Phase r---7 3 Phase F_7 Source: Ceiling—X_ Cord and Cap—X_ l'1 Mobility l'l Locking Casters X Flanged Feet l/l Delivery Site: Loading Dock Ground Level l/l Delivery hours: Depth of case is is 46"which will fit through l � narrowestace between delivery point and install location Yes No T If no—CALL US ASAP] Approval signature: See last page for specifications table—your signature above verifies the installation site has the required power as shown Merchandising • shelves on both Access doors on both long ends ends to hot wells and • rr► �� g en heat lamp controls N Scroll down for more views 5—pan Hot Food ��� Details per sign off on page 1 and Ahold u specifications on last page r� IP #MHFC7344-ECB-UO-DA 1 Delhaize 73"L x 44" D x 56" H Approval signature: v [Date: Top feed connection Long Goss box, supply cord 73" and plug (cord&plug not MASTER shown) APPROVAL DRA WINGS Drain outlet on one short end ,Breaker panel on one short end (2) hot wells and heat lamps,00� controls behind hinged access doors on this side 0000 (3) hot wells and heat lamps controls behind hinged • access doors on this side Casters— (2) LockingAtlantic Food Bars CO Hot. . I „d Merchandising SpecialistsEquipment Scroll down for more views C Ahold 5-pan Hot Food Bar Details per sign off on page 1 and IP #MHFC7344-ECB-UO-DA specifications on last page 1 Delhaize 73" L x 44" D x 56" H Approval signature: MASTER APPROVAL DRA WINGS abate: s Goss Section SMALL WARES PACKAGE to be quoted upon request Example—Food Lion Pan Package includes: 4 4" ➢ (20)Half long stainless steel food pans x 2 '/_2"deep ➢ (12) 20"Adapter bars ➢ (10) 12"x 20"Lid covers Fn ➢ (40) Stainless Steel/Silicone 9"Heat resistant tongs o ➢ (5) 60oz water pitchers 1 72 73 12 2„ 64 -------- --- 447, 567 1 EI[I 36,, 18 Plan View (5) Standard 12"x , 20"warming wells NO O.A. CAPACITY ELECTRICAL . •+'° Bars IP CODE DIMENSIONS HOT t L"X W"X H" 12 X 20 VOLTAGE AMPS MCAFood Merchandising Equipment Specialists MHFC7344-ECB-UO-DA 73 x 46 x 56 5 120/208 42.3 - l O 52.9 37.3 - 30 37.3 SOLUTIONS ; Ww-matlanticf6odbars.com i Operations and Maintenance Manual Sewage Collection and Treatment Facilities Cotuit Landing Route 28 Barnstable, Massachusetts Prepared for Stop & Shop Supermarket Company Quincy, Massachusetts 02169 Prepared by VM/Vanasse Hangen Brustlin, Inc. Watertown, Massachusetts 02471 and ZENON Environmental, Inc. Oakville, Ontario, Canada L6M 4B2 July 2001 Revised December 2001 M\LD\05162Tms\memo\was1ewater\ . Treatment\Cotuit O&M 2_VHBformat Operations and Maintenance Manual Sewage Collection and Treatment Facilities Cotuit Landing Route 28 t Barnstable, Massachusetts Prepared for The Stop &Shop Supermarket Company 1385 Hancock Street Quincy,Massachusetts 02169 Prepared b IMNanas a Han en B p y s g rustlin,Inc. Transportation,Land Development,Environmental Services 101 Walnut Street P.O.Box 9151 Watertown,Massachusetts 02471 k and ZENON Environmental,Inc. 3239 Dundas Street West Oakville,Ontario,Canada L6M 4B2 July 2001 Revised December 2001 KLM051620 s\memo4astewateA TreatmenACotui O&M 2_VHBformat �j I17� Vanasse Hangen Brustlin,Inc. i Table of Contents 1.Introduction........................................................................................................................1 2.Permits and Operational Requirements........................................................................3 3.Description of Wastewater Treatment Facilities..........................................................5 t SettlingTank..............................................................................................................................5 GreaseTraps.............................................................................................................................5 Equalization Tank&Pump Station.............................................................................................6 Zenon Wastewater Treatment Facility........................................................................................7 EffluentDisposal........................................................................................................................7 SpecialDesign Features............................................................................................................8 4.Description of Bio-Solids Handling Facilities...........................................................10 General.....................................................................................................................................10 Designated Sludge Hauler and Disposal Facilities...................................................................10 Waste Hauler(Tentative)..........................................................................................10 Solids Disposal Facility.............................................................................................11 Backup Solids Disposal Facility................................................................................11 5.Personnel...........................................................................................................................12 Qualifications.........................:...................................................................................................12 Personnel.................................................................................................................................12 Contract for Professional Services...........................................................................................13 Operation and Maintenance of the Zenon System...................................................13 Preventative Maintenance of Electrical Components...............................................13 6. Sampling and Analysis...................................................................................................14 OperationalGuidelines.............................................................................................................14 Influent Sampling at the Recycle Tank.....................................................................................14 EffluentSampling.....................................................................................................................15 ProcessMonitoring...................................................................................................................15 Sampling and Laboratory Protocol...........................................................................................16 EquipmentCalibration..............................................................................................................16 7.Facility Records and Reporting........................................................................:............17 8.Emergency Operations&Response.............................................................................19 Fire and Medical Emergencies..........:......................................................................................19 Spill Control and Reporting. ..19 M\LD\051620ocs\Memos\was1ewater Treatment\Cotuil O&M 2_VH8torma1 ii Contents I VB Vanasse Hangen Brustlin,Inc. Table of Contents (continued) EmergencyConditions.............................................................................................................20 IdentifyEmergency...............................................:...................................................21 InitialInvestigation....................................................................................................21 InitialAction..............................................................................................................22 CorrectiveAction......................................................................................................22 Follow-up..................................................................................................................22 Emergency Preparedness........................................................................................23 f Summary..................................................................................................................23 Possible Emergency Conditions...............................................................................................24 Failure of Commercial(Primary)Power....................................................................24 GStorms......................................................................................................................25 Explosions................................................................................................................26 Fires..........................................................................................................................27 Hydraulic Overloads, Ruptures and Blockage..........................................................28 Equipment Breakdowns and Process Failures.........................................................29 Spills of Oils,Acids,Toxic or Hazardous Materials..................................................30 PersonnelInjury........................................................................................................31 Emergency Readiness Program...............................................................................................31 Emergency Telephone Numbers..............................................................................31 Emergency Equipment Inventory..............................................................................31 Treatment Facility Records..................:. ...............................................................31 Coordination with Police and Fire Department.........................................................32 9. Safety..................................................................................................................................33 10.Utilities.............................................................................................................................36 ` 11. Supplies and Maintenance Schedule.........................................................................37 Lt SpareParts and Supplies.........................................................................................................37 SafetySupplies.........................................................................................................37 MaintenanceSchedule.............................................................................................................38 TelephoneIndex..................................................................................................................39 Treatment Plant Operator(Tentative).......................................................................................39 ConsultingEngineer.................................................................................................................39 Waste Hauler(Tentative)................................................:........................................................39 Solids Disposal Facility Backup Solids Disposal Facility................................................................................................40 Testing Laboratory ....40 . .................. GeneralContractor...................................................................................................................40 M M051620ocs\Memos\w stemler Treatment\Cotuu O&M 2_VHBformat iii Contents i f VB Vanasse Hangen Brustlin,Inc. Table of Contents EquipmentSuppliers................................................................................................................40 Zenon Units..................... Pump Station Pumps and Controls(Tentative)........................................................41 LocalMedical Facilities............................................................................................................41 Utilities......................................................................................................................................41 DigSafe....................................................................................................................41 Electric......................................................................................................................41 1 Gas...........................................................................................................................41 %�. Telephone.................................................................................................................42 Water........................................................................................................................42 Reporting..................................................................................................................................42 Emergency Numbers(Emergency and Business)....................................................................43 PublicSafety.............................................................................................................43 DEPEmergency Response......................................................................................43 Operations................................................................................................................................43 Facility (Tentative)...................................................................................................43 Owner.......................................................................................................................43 Appendices AppendixA DEP Certifications................................................................................................. Appendix B Reporting Forms................................................................................................... Appendix C Operating Contracts.............................................................................................. AppendixD Zenon System....................................................................................................... Appendix E Control Diagrams and Pump Stations.................................................................. Under Separate Cover Material Data Safety Sheets.......................................................................................................... 310 CMR 11.00 through 17.00..................................................................................................... AsBuilt Site Plans........................................................................................................................ M0.0\05162\0o sNemos\wastemter 7 Treatment\ColuH O&M 2_VHMormal 1V Contents . Vanasse Hangen Brust in,Inc. Tables Table No. Description Page 3.1 Typical Sludge Characteristics.................................................................7 f�1 r M\LD\0S1 fit\Dots\Memos\mstemter �� TreatmeM\Cotua O&M 2_VHBfor al v Contents Ii1D Vanasse Hangen Brustlin,Inc. Introduction This manual has been prepared to provide information relating to the operations and maintenance of the wastewater treatment facilities serving the redeveloped and expanded Cotuit Landing located on Route 28 in Barnstable,Massachusetts. In addition to the facilities located at the wastewater treatment plant,the sewerage system includes a gravity wastewater collection system for the three(3)existing and three(3)proposed buildings on the site. The wastewater treatment facility is designed to handle a design flow of 21,600 gallons per day of sewage via a Zenon Membrane Bioreactor treatment system. The system is capable of providing tertiary levels of wastewater treatment,reducing the dissolved organic and nitrogen content of the wastewater to disposal via a subsurface disposal system. Wastewater is conveyed to the treatment facilities using gravity sewer lines from all existing and proposed buildings on site. Kitchen wastewater from the Stop&Shop flows by gravity to a 4,000 gallon grease trap,then by gravity it combines with all other wastewater generated on-site in a lift station. The lift station pumps the sewage to an 11,000 gallon settling tank. From the settling tank,wastewater effluent flows by gravity to a 22,000 gallon equalization tank and pump station which pumps sewage to the indoor Zenon Wastewater Treatment Facility. The following is a sequential listing of the components comprising the wastewater treatment facility: > One(1) 11,000 gallon precast concrete settling tank; > One(1)pre-cast concrete equalization tank with pump station(22,000 gallon capacity) > One(1)Zenon Membrane Bioreactor(concrete tank) > One(1)precast concrete Pressure Dose pump chamber > Two(2) alternating final effluent dosing pumps(in Pressure Dose Pump Chamber) M\LD\05162\Docs\Memoftas1ew ter � Treatment\Ootuh O&M2 VHBtormat 1 Introduction MVanasse Hangen Brustlin,Inc. > Two(2)4,340 square foot leaching areas(two(2)4,340 square foot reserve areas are provided) > One precast concrete irrigation storage tank will be the dosing volume in the pump station wetwell. This document provides information pertaining to facility permits and approvals, descriptions and discussions of the wastewater treatment and sludge handling facilities,sampling,record keeping,emergency response,safety and equipment maintenance. An updated copy of this manual,in addition to other pertinent documents and . records,will be maintained at the facility. s i . r 1� M\LD\06162\Dms\Memos\wastewater Treatmenl\Coluit O&M 2_VHBfo"at 2 Introduction VB Vanasse Hangen Brustlin,Inc. 2 Permits and Operational Requirements The Massachusetts Department of Environmental Protection,Division of Water Pollution Control granted final approval of the Sewage Treatment Facility for the redeveloped and expanded Cotuit Landing located on Route 28 in Barnstable, Massachusetts on July 24,2001. A complete set of the approved final design plans must be maintained at the treatment facility. 1 In accordance with the P Y permit issued b the Department of Environmental Protection,the following conditions must be met in order to operate the facility within full compliance: > Daily sewage flow shall be 21,600 gallons per day or less. > The system shall be continuous) maintained under an O&M agreement, Y Y g throughout its life. Refer to Chapter 5 of-this document for details of this requirement. > An O&M agreement for the proper disposal and pumping of sewage and grease shall be maintained throughout the life of the system. Refer to Chapter 4 of this document for details of this requirement. > The system shall be operated within set discharge limits as described in Chapter 6 of this document. > The system shall be monitored following the schedule as described in Chapter 6 of this document. Said results are to be reported in an accurate manner on.a timely basis to the Department of Environmental Protection as described in Chapter 7 of this document. > No changes may be made to the approved system without the prior written approval of the Department. > The owner shall take all corrective action deemed necessary by the Department of Environmental Protection and the Barnstable Board of Health in the event of system failure:or imminent system-failure. M\LD\05162\Dots\Memos\was1ewa1er \� Cotuit O&M 2_VHBlormat 3 Permits and Operational Requirements i I17� Vanasse Hangen Brust in,Inc. > If title to the property or any portion of the property is to be transferred,prior to signing a purchase and sale agreement,the seller/owner shall inform the new owner of past water usage,off-site pumping records of the system,and the conditions of the DEP approval. 1 M\LD\05162\Does\Memos\was1ewater Colui108M 2_VHBformat 4 Permits and Operational Requirements i B Vanasse Hangen Brustlin,Inc. 3 Description of Wastewater Treatment Facilities This Section is intended to provide a description of the various treatment plant T s Sect o p p p t components and their function. Each component is presented in a sequential order and discussed individually in the following Sections. r. Settling Tank The one(1) 11,000 gallon settling tank will remove primary solids and floating debris in the raw wastewater. The influent pump station is equipped with grinder pumps to macerate the incoming waste flow prior to discharge to the settling tank. "Settling tank"shall be pumped whenever necessary to ensure proper functioning of the system. Pumping is required whenever the top of the sludge or solids layer is within 12 inches or less of the bottom of the outlet tee or the top of the scum layer is within two inches of the top of the outlet tee or the bottom of the scum layer is within two inches of the bottom of the outlet tee. Pumping frequency is a function of use, although pumping is typically necessary at least once every year. For this system,semi-annual cleaning of settling tank is highly recommended. Grease Traps There,are two grease traps located at the Cotuit Landing site,one.at Retail A(1,000 gallon)and one at the Stop &Shop(4,000 gallon). Grease traps are watertight structures located on a building sewer before a septic tank in which grease and oils . are separated from other solid and liquid constituents of sewage. ,Grease traps should be inspected monthly and shall be cleaned by a licensed se to a hauler whenever the level of grease is 25%of the effective depth of the trap, p g g p p or at least every 3 months,whichever is sooner."310-CMR 15.351 M\LD\05162\Dots\Memos\was1ewa1er Treatment\Cotuit O&M 2_VHBformat 5 Description of Wastewater Treatment Facilities VB Vanasse Hangen Brustlin,Inc. Equalization Tank & Pump Station The 22,000 gallon Equalization Tank and PumpStation(dual pumps)are located P p after the 11,000 gallon settling tank and feeds the Zenon wastewater treatment i iff facility. The pumps deliver primary settled effluent to the Zenon System.. Liquid level control switches are located in Pump Station and govern the following functions: > Low Water Alarm: The low level sensor will activate the audio/visual alarm when the circuit is closed. > Pump Off: This sensor will create an open circuit and prevent operation of the pumps. However,the pumps may be manually activated when the circuit is open. When the circuit is closed,the sensor will activate the timer and alternate the pumps. This sensor is located at the bottom of the"working volume"of the pump chamber. > Lead Pump On: The actuation of this sensor will trigger the start of the lead pump. This sensor is located at the top of the"working volume"of the pump chamber. > Lag Pump On/High Water Alarm A high level sensor will create a closed circuit and activate the lag pump. The two pumps will then empty the chamber to the low-level condition. The high water sensor will activate the audio/visual alarm when the circuit is closed.This will allow the operator to periodically test the high-level alarm. The pump station controls are located in the adjacent Zenon Wastewater Treatment Facility building. An annunciator and flashing light are mounted on the outside wall of the Zenon Wastewater Treatment Facility building. i M\LD\051620 s\Memos\waster ter Treatment\Cotu0 O&M 2_VHBtormat 6 Description of Wastewater Treatment Facilities f VB Vanasse Hangen Brustfin,Inc. Zenon Wastewater Treatment Facility Table 3.1 Typical Sludge Characteristics Range Typical Total dry solids(TS),% 6.0-12.0 10.0 Volatile solids(%of TS) 30.0—60 40.0 Grease and fats(ether soluble,%of TS) 5.0-20.0 Protein(%of TS 15.0—20 18.0 Nitrogen(N,%of TS) 1.6-6.0 3.0 Phosphorous(P205,%of TS) 1.5-4.0 2.5 Potash(K201%of TS) 0.0-3.0 1.0 Cellulose(%of TS) 8.0-15.0 10.0 Iron(not as sulfide) 3.0-8.0 4.0 Silica(SiO2,%of TS) 10.0—20 15.0 pH(standard units) 6.5-7.5 7.0 Alkalinity(mg/I as CaCO,) 2,500-3,500 3,000 (Source: Metcalf&Eddy,Wastewater Engineering,1991) Effluent Disposal Effluent is collected in the Pressure Dose Pump Chamber. Pumps then discharge to the leaching fields. Four control float switches are located in Pressure Dose Pump Station and govern the following functions: > Low Water Alarm: The low level float switch will activate the audio/visual alarm when the circuit is closed. > Pump Off:In the extended position this float switch will create an open circuit and prevent.operation of the pumps. However,the pumps may be manually activated when the switch is extended and the circuit is open. When the circuit is closed,the float switch will activate the timer and alternate the pumps. This float is located at the bottom of the"working volume"of the pump chamber. ` > Lead Pump On: The actuation of this float will trigger the start of the lead pump. This float is located at the to of the"working volume"of the um chamber. P g pump > Lag Pump On/ Water Alarm A high level float will create a closed circuit and activate the lag pump. The two pumps will then empty.the chamber to the low-level condition. The high water float switch will activate the audio/visual M\LD\05162\Dots\Memos\wastewa1er Treatment\Cotuit O&M 2_VHBformat 7 Description of Wastewater Treatment Facilities VB Vanasse Hangen Brustlin,Inc. alarm when the circuit is closed.This will allow the operator to periodically test the high-level alarm. The pump station controls are located in the Zenon Wastewater Treatment Facility building located adjacent to the Stop&Shop. The effluent disposal area is located in the Stop&Shop front parking field. The disposal system consists of two(2)leaching areas. Each of the leaching areas measure 62 feet by 70 feet and are dosed by perforated laterals fed from a single manifold. Maintenance requirements for the leaching system should be minimal. The effluent disposal system should be periodically monitored to ensure the absence of effluent ponding. Special Design Features The facility has been designed to provide safe and efficient operation. The design also includes contingencies intended to prevent any bypassing of treatment processes in the event of a system failure. Redundancy Duplicate pumps have been installed wherever pumping is required. Each of these pumping systems is capable of handling the required flow to the Zenon System with the largest unit out of service. An equalization tank is provided with the capacity to handle nearly one full days of design flow. Emergency Generator The Generator is located adjacent to the Zenon Wastewater Treatment Facility building and is designed to provide power for both the Zenon Wastewater Treatment Facility. The generator will be maintained by Stop&Shop. Spare Parts Inventory An inventory of recommended spare parts shall be maintained to facilitate repairs. All spare parts must be stored within the manufacturer's recommended environmental conditions. Refer to Chapter 11 of this document for a complete updated listing of spare parts. Safetysupplies shall be provided b the treatment plant operator. PP P Y p p �t M\LD\05162\Dmc Memos\mstewater Treatment\COtuft O&M 2_VHBtomat 8 Description of Wastewater Treatment Facilities I11U Vanasse Hangen Brustlin,Inc. Flow Measurement Influent flow and effluent flow monitoring shall be preformed before the Pressure Dose Pump Chamber in the form of water meter readings. Flow readings shall be taken from the water service meters installed by the District. Safety Equipment Pertinent safety equipment including a first aid kit,fire extinguisher,emergency - lighting and smoke detectors is provided. An emergency eye wash station is also installed within the underground utility vault. 1� Control Room All electrical controls are located in the Zenon Wastewater Treatment Facility building. Electrical fixtures are enclosed in lockable NEMA 3R and 4X cabinets. Alarms Alarms are provided to signify high water level or failure of any pump,motor or fan. The alarm system includes visual and audible alarms mounted on the outside of the wastewater treatment facility. M\LD\05162\Dms\Memos\was1ewater TreatmerMCotud O&M 2_VHBtormat 9 Description of Wastewater Treatment Facilities 7 IM Vanasse Hangen Brustlin,Inc. .4 Description of Bio-Solids Handling Facilities General ' The treatment process utilized at the Stop &Shop Plaza Wastewater Treatment Facility generates waste solids that require handling separate from the wastewater treatment system.Waste solids are captured in the Zenon Bio-Reactor by the membrane filter process. Bio-Solids are removed from the Reactor on an intermittent basis by means of a sludge pump. The removal frequency is based on the concentration of mixed liquor suspended solids in the Bio-Reactor and will be removed on the basis of Zenon recommendations for maximum solids levels. The Membrane filter collects solids as a natural art of the filtration process. Waste P solids are cleared from the filter when it is backwashed Solids generated by the Zenon facilities are stored in the reactor tank.Consequently, this tank should be monitored for sludge depth. The sludge collected in this tank will be removed by a sewage pump truck. In addition,the settling tank collects sludge at the bottom of its tank and scum which accumulates on the liquid surface of this tank. This tank sludge and scum should also be removed at least twice each year. Designated Sludge Hauler and Disposal Facilities ■ " Waste Hauler(Tentative) Bousfield Sanitary/Bouse House Enterprises Route 28 Yarmouth,MA PH: (508)398-1135 M\LD\051620m Memos\wastewater Treatment\C tuft O&M 2_VHBforrnat 10 Description of Bio-Solids Handling Facilities VB Vanasse Hangen Brustlin,Inc. ■ Solids Disposal Facility Yarmouth-Dennis Septage Treatment Facility Managed by AquaSource,Inc. 47 Workshop Road South Yarmouth,MA 02664 PH: (508)760-2414 FX: (508)760-2990 ■ Backup Solids Disposal Facility Massachusetts Environmental Services,Inc. 1 Meade Road PO Box 36 North Carver,MA 02355 PH: (508)866-8140 FX: .i M\LD\05162\0ots\Memos\was1ewater Treatmem\Cotuit O&M 2_VHBtormat 11 Description of Bio-Solids Handling Facilities VB Vanasse Hangen Brustlin,Inc. 5 Personnel Qualifications The facility will be staffed by a Chief Operator and Operators who must devote part of their time to general attention of plant process operations,daily report requirements,and routine housekeeping and maintenance chores. The majority of the operators time will be spent conducting laboratory testing,equipment maintenance and repair,and general plant process attention. The chief operator of the Sewage Treatment Facility at Cotuit Landing shall be certified by the State Board of Certification of Operators of Wastewater Treatment Plants in accordance with the requirements of 257 CMR 2.00 and shall have the following qualifications: > Grade: Commonwealth of Massachusetts Grade 4 Wastewater Treatment Plant Operator,at a minimum. > Experience:At least one year as a Grade 4 Operator working under the supervision of an operator with a Grade 4 License. > A backup operator possessing at least a Grade 4 license is designated. All other personnel employed at the facility shall be familiar with the operations of wastewater treatment facilities. Such personnel shall work under the direction and supervision of the chief operator. e made to provide�continuin education and training for all Every effort should b p g g plant personnel. Operators should be encouraged to take advantage of those courses offered in the Commonwealth of Massachusetts. Subscription to trade magazines and membership in the local chapter of Water Pollution Control Federation will also aid in providing continuing education. Personnel The Owner shall employ sufficient personnel to ensure the proper operation of the facility. At a minimum,the Owner shall employ a chief operator with the M\LD\05162\Dxs\Memos\ 12 Personnel Cotuit O&M_VHNoonat �B Vanasse Hangen Brustlin,Inc. qualifications outlined in Section 5.1. An assistant operator shall also be assigned to perform plant duties in the absence of the chief operator.Each visit shall be of sufficient duration(at least 3 hours)to permit the proper inspection of equipment and to check the performance of equipment and perform other duties. The Chief Operator or his assistant shall be on call 24 hours a day,seven days a week,in the �. event of an emergency. Contract for Professional Services At the time of this writing,the Owner has chosen to contract various aspects of the operation of the facility. We have discussed this operation potential with Whitewater,Inc.who has experience with the Zenon Systems. Other operator options may be contracted,provided they have experience with the Zenon system and have requisite Certified Operators under Massachusetts regulations. ■ Operation and Maintenance of the Zenon System To be Decided ■ Preventative Maintenance of Electrical Components Kay Construction Corporation (Tentative) 49 Winchester Street P.O.Box 610307 Newton,MA 02461-0307 PH: (617)969-0606 FX: (617)969-0505 w MLLM051621Dms\Memos\ 13 Personnel Cotui 0&d_WWomlat B Vanasse Hangen Brustlin,Inc. 6 Sampling and Analysis Operational Guidelines The maximum effluent concentrations discharged from the Zenon Wastewater Treatment system shall not exceed the following: Parameter Limit Flow 21,600 gallons per day BOD5 30 mg/L Total Suspended Solids(TSS) 30 mg/L Oil and Grease 15 mg/L Total Nitrogen(NO2+NO,+TKN) 10 mg/L Additionally,effluent pH shall not vary more than 0.5 standard units from the influent water supply. Influent Sampling at the RecycleTank The influent waste stream to the facilityhall s be sampled prior to the wastewater treatment facility and tested for the following parameters specified below: Parameter Frequency Y p YP Sample Type Flow Daily Flow Meter BOD5 Weekly 12 hour composite Total Suspended Solids Weekly 12 hour composite Total Nitrogen Weekly 12 hour composite J These samples should be taken from the wet well of Lift Station 1. All samples shall be 12-hour composites,with the exception of pH and oil&grease,which shall be obtained from grab samples. Flow shall be measured from system flow meter readings;Flow readings should be taken at approximately the same time each day. Any grab sample or composite sample required to be taken less frequently than daily M\LD\05162 ms\Memos\Wastemter Treatment\Cotuit O&M 2_VH8tormat 14 Sampling and Analysis i B Vanasse Hangen Brustlin,Inc. shall be taken during the period of Monday through Friday,inclusive. All composite samples shall be collected over the operating day. Effluent Sampling The effluent from the facility shall be sampled from the Pressure Dose Pump Chamber and tested for the parameters specified below: Parameter Frequency Type of Sample _ Flow Daily Flow Meter BODS Weekly 12 hour composite Total Suspended Solids Weekly 12 hour composite pH Weekly Grab Oil and Grease Weekly Grab Total-Nitrogen Weekly 12 hour composite Nitrate-Nitrogen Weekly 12 hour composite Total Alkalinity Weekly 12 hour composite All samples shall be 12-hour composites,with the exception of H and oil&grease, P P P P which shall be obtained from grab samples. Flow shall be measured by a flow meter; meter readings should be taken at approximately the same time each day. Any grab sample or composite sample required to be taken less frequently than daily shall be taken during the period of Monday through Friday,inclusive. All composite samples shall be collected over the operating day. The Monitoring wells MNl to MW5 shall be sampled and tested for the same parameters as the Effluent. The monitoring wells shall be sampled and tested on a quarterly interval. Process Monitoring The entire treatment facility has been designed to be fully automated,controlled by the Equipment Control Panel. All time sequences have been preset based upon experience at other similar installations and manufacturer's recommendations. There are no routine process control functions to be performed by the operator and adjustments should only be necessary in the event of an unusual circumstance. The treatment facility has been designed to minimize operator attention requirements. Wastewater analysis is only necessary to monitor overall plant performance and to identify and correct specific problems. The laboratory analysis required by the Massachusetts Department of Environmental Protection in the facility's discharge permit will provide an important chronology=enabling the plant M%LD1051620wMemos\Wastewater Treatment\CoIO O&M 2_VHBfonnat 15 Sampling and Analysis Ill U Vanasse Hangen Brustlin,Inc. r operator to interpret and predict unusual events. This data needs only to be supplemented with a record of daily visual and olfactory observations. A visual inspection should be made of all of the facility's unit processes each day of operator coverage. The plant operator should refer to the operation and maintenance manuals of the individual equipment suppliers located in the appendices of this report for additional details on problem identification and appropriate corrective measures. Should an operational problem occur,the operator may find the need to conduct additional wastewater testing during the month to aid in identifying the problem. Such testing should be performed at the operators discretion and might include: > raw wastewater temperature,pH and alkalinity; > influent ammonia and nitrate-nitrogen concentrations > influent and effluent BODE > process dissolved oxygen levels. Sampling and Laboratory Protocol All sampling,sample preservation and analyses shall be performed utilizing procedures approved by the Department of Environmental Protection(DEP). In addition,effluent and groundwater samples shall be analyzed by a Commonwealth of Massachusetts certified laboratory. Equipment Calibration A pH meter should be maintained at the treatment plant for use by the plant operator in monitoring the pH of samples collected as required in the facility's discharge permit. The meter should be calibrated against standard solutions of known pH prior to each use.A fresh supply of standard solution should be obtained each month from the contracted laboratory. The plant operator should refer to the instructions provided with the pH meter for more comprehensive details on proper calibration procedures. The use and care of the instrument should be in strict accordance with the manufacturer's recommendations. Water meters used in the measurement of influent and effluent flow shall be calibrated and maintained according the manufacturer's recommendations. r` M\LD\05I620 s\Memos\Wastewater Treatment\CotuA O&M 2_VHBfonnat 16 Sampling and Analysis VM Vanasse Hangen Brustlin,Inc. 7 Facility Records and Reporting The operator shall maintain a log of plant operations,process changes and C equipment maintenance. At a minimum,the following information should be recorded in the facility's log: > Results of monthly influent and effluent monitoring as required by the approval; > Recordings of wastewater flows as required by the approval; > Results of monitoring of other wastewater characteristics; > Date and quantity of sludge removed from the facility; > Physical changes in the biological growth; > Process changes; > Equipment maintenance records; > Equipment failures and replacements; > Emergency situations. Copies of the logs,as well as the monthly inspection reports,shall be kept at the facility at all times. It is recommended that the operator shall also report any of the following to the Department of Environmental Protection,Division of Water Pollution Control,Southeast Regional and Boston Offices: > Planned physical alterations and additions to the facility; > Anticipated non-compliance; > Occurrence of a facility non-compliance(reported within 24 hours);and > Any proposed flow changes. All facility record keeping and reporting shall meet the requirements of the Massachusetts Permit Program(BRP WP 06). Record keeping and reporting on the operation of the treatment plant and related appurtenances must also conform to the provisions of the variance. Specifically, monthly operating records shall be maintained by the plant operator in accordance with the most recent edition of the Department of Environmental Protection, Division of Water Pollution Control's publication entitled"Directions for Completing Monthly Report Forms for Wastewater Treatment Plants"and submitted on forms supplied by the Division. A copy of the regulations,instructions and reporting forms supplied by the Division are included in Appendix B. ' M\LD\05162\Dms\Memos\Wastewater Treatment\Cotuft O&M 2_VHBtormat 17 Facilities Records and Reporting IiLJ Vanasse Hangen Brustlin,Inc. A yearly written report shall be submitted to the Department of Environmental Protection and the Barnstable Board of Health. This report shall describe all monitoring,pumping,servicing,and inspection information collected on the system for the previous calendar year. Said report shall be submitted by January 31 of the following calendar year and shall be in a format acceptable to the Department. All monitoring data shall be submitted to the Department at the following addresses within 30 days of the sampling date: Department of Environmental Protection Division of Water Pollution Control One Winter Street Boston,MA 02108 and Department of Environmental Protection Division of Water Pollution Control 20 Riverside Drive Lakeville,MA 02347 • M\LD\05162\Dots\Memos\Was1ewa1er Treatment\Colut O&M 2_VHBfonat 18 Facilities Records and Reporting B Vanasse Hangen Brustlin,Inc. 8 Emergency Operations & . Response - Fire and Medical Emergencies The following agencies shall be contacted when a fire or medical emergency occurs at the treatment plant: Emergency Business Ambulance 911 Barnstable Fire Department 911 Barnstable Police Department 911 A fire at the facility also necessitates that the Department of Environmental Protection,Division of Water Pollution Control,Southeast Regional Office be contacted at(508)946-2714. A written report shall be prepared following any fire emergency assessing damage to the facility and proposing a schedule of remedial action. This report shall be sent to the agencies listed in the next section of this document. If possible,all electrical power to the facility and emergency generator should be shut down during fire emergencies. Spill Control and Reporting In the event of an overflow or accidental spillage of untreated wastewater or sludge, the following authorities shall be contacted immediately: Department of Environmental Protection (508)946-2714 Division of Water Pollution Control Southeast Regional Office 20 Riverside Drive Lakeville,Massachusetts 02347 M\LD\05162\Dots\Memos\Was1ewa1er Treatment\Cotud 08M 2_VH8format 19 Emergency Operations and Response VB Vanasse Hangen Brustlin,Inc. Department of Environmental Protection (617)292-5500 Division of Water Pollution Control Boston Office One Winter Street Boston,Massachusetts 02108 1 DEP Emergency Response Monday through Friday(9:00 AM to 5:00 PM) (978)661-6681 After Hours,Weekends&Holidays (617)292-5500 Barnstable Board of Health (508)862-4644 A written report shall be prepared,and submitted to the above agencies,describing the event,required remedial actions and the steps to prevent a future occurrence. Emergency Conditions Emergency conditions can be imposed on a treatment system by natural disasters, civil disorders,faulty maintenance,negligent operation and accidents. Planning is essential to ensure continued effective operation during emergency situations This chapter of the Operations and Maintenance Manual provides a detailed account of the emergency response plan necessary for ensuring the continued effective operation of the wastewater treatment facility under emergency conditions. The objectives of this emergency response plan are: > To eliminate or minimize adverse effects from emergency situations affecting the s Y s II treatment system; > To develop procedures for properly responding to emergencies;> To provide instruction for system personnel to ensure that they understand their responsibilities during emergency situations;and, ' > To provide inventories of available emergency equipment and outline existing mutual aid agreements and contracts with outside organizations for specialized assistance. It is important for the operators to recognize what procedures should be followed in the event of an emergency. Emergency situations are of varying degrees of seriousness. In any event,the operators shall take any and all actions to achieve: > Safety of personnel within the plant and the surrounding area. ' > Safety of equipment within the plant area. > Best treatment of sewage,,given the emergency situation. I M\LM051620 s\Memos\Wastev ler Treatment\CoIO O&M 2_VHBlormat 20 Emergency Operations and Response VB Vanasse Hangen Brustlin,Inc. There is a logical sequence of steps in responding to any emergency,which should be followed by the operator on duty. The response sequence includes identifying the emergency,investigating and assessing the severity of the emergency,determining ' the proper initial course of action,implementing the corrective action to rectify the situation and following up with a post-emergency investigation and report. ■ Identify Emergency This step is obvious for most situations and is essentially that of becoming aware that an emergency exists. Natural disasters,power failures,equipment breakdowns and injuries are usually rather dramatic and will seize the operator's attention almost immediately upon occurrence. Under certain circumstances,the operator may have prior warning of an impending emergency through weather reports or through trends in process or equipment performance. Some impending emergency situations exist long before the operator is aware that a problem exists. These situations may produce a larger emergency which then becomes more immediate and obvious. Poorly maintained equipment may have minor breakdowns,which,if gone unnoticed,may lead to complete failure of the equipment with possible injury to unwary plant personnel. A spill or discharge of toxic or hazardous materials into the contributing sewerage system is another example of an emergency situation that may o unnoticed for an extended period of P g Y Yg time. If no waste monitoring and warning system exists,the operator will not be aware of the emergency until a treatment process fails or until the plant alarm system activates. Initial Investigation ' Once the operator becomes aware that an emergency situation exists or that a natural disaster is imminent,an initial investigation should be immediately initiated. This ' investigation is undertaken to assess the severity of the emergency and to gather the information necessary for determining a proper initial course of action. Under emergency conditions,the operator should assess the seriousness of injury to personnel and damage to structures and equipment,noting possible impending damage,which could occur if corrective action is not immediately undertaken. The operator should then list personnel and emergency equipment immediately necessary to remedy the situation. M\LD\05162\Dms\Memos\W astem1er Tmtment\Ootuft O&M 2_VHBforma1 21 Emergency Operations and Response ' B Vanasse Hangen Brustlin,Inc. Initial Action Once the severity of the emergency is known,the operator should make a ' determination as to what initial action should be undertaken. This initial action usually consists of notifying responsible authorities and calling for necessary assistance in order of priority. ' After the necessary calls,the operator should immediately initiate action within specified limits to remedy the situation. The operator should not endanger himself or other plant personnel by undertaking tasks for which the proper personnel or equipment are not available. If the operator is not familiar with first-aid techniques; he should not attempt to move injured persons unless further danger exists. Moving an injured person or attempting first-aid without proper knowledge of the technique may cause more serious,permanent injury. ■ Corrective Action 1 If handling the emergency is beyond the operator's capabilities,he should wait until the necessary assistance is available. The operator should immediately appoint the proper personnel to supervise the corrective action. While corrective actions are I being undertaken,the operator should notify all relevant agencies and persons not informed initially. Corrective action should be continued until the emergency situation is completely reconciled. If the correction will take a considerable amount of time,necessitated by equipment orders,etc.,the operator should consult with the necessary parties to outline a long-range program to complete the task. ■ Follow-up After the emergency situation has been corrected,the operator should make every effort to determine the cause of the emergency and to review the corrective actions implemented. The operator should then undertake preventive measures to minimize the possibility of recurrence. In the case of accidents,the operator should institute stricter safety practices,as outlined in the WPCF Manual of Practice No. 1,Safety in Wastewater Works. In the case of equipment failure,if negligence was not the problem,then a revised maintenance schedule would be the most likely preventive measure. For natural disasters,which cannot be prevented from recurring,corrective measures may be undertaken to minimize the severity of the emergency. In any case,the procedures W LD\05162\Doa\Memos\Wastewater Trea1me,ACo1u108,112_VHBformat 22 Emergency Operations and Response IM Vanasse Hangen Brustlin,Inc. ' in dealingwith an emergency situation should be reviewed to develop more effective S Y P ' courses of action. For all emergencies,the Massachusetts Department of Environmental Protection, 1 Division of Water Pollution Control should be notified and a follow-up report made, detailing what happened and how the situation was handled. Also,the operator should ask for and expect assistance from this agency when the situation warrants. ■ Emergency Preparedness In order to alleviate confusion during an emergency,and to be prepared for emergency situations,the following actions shall be taken: > A telephone list of emergency numbers should be retained by the treatment plant operator. The list should include fire,police,utility companies,highway department,sewer department personnel and others who should be contacted during emergencies. ' > At times of predicted storms or other natural phenomena which may create emergencies,all relevant personnel should be on duty at the treatment plant. > Arrangements for the use of battery powered radios and other necessary equipment should be made. ' > All vehicles, generators,portable pumps,compressors and other emergency tools and equipment should be fueled and in good repair for immediate use. > Develop a program for training personnel in emergency operation procedures. Work closely with Town Police and Fire Departments(who are familiar with such programs). ■ ' Summary This section outlines a general pattern of response actions which the operator should follow in responding to emergencies. In most small emergencies the operator will go through these steps automatically;however,they should be reviewed periodically in order to effectively deal with major emergency situations. In general,the sequence of response actions is: > IdentifY emergency. . Y > Investigate and assess the severity of the emergency. > Take initial action and notify responsible authorities. > Implement corrective action to rectify the situation. M\LD\05162\Dots\Memos\Was1ewa1er Treatment\CotuR O&M 2_VHBfonnat 23 Emergency Operations and Response i ' VB Vanasse Hangen Brustlin,Inc. > Follow up with an investigation to prevent or minimize future similar emergencies. Possible Emergency Conditions In a treatment system,the following emergency situations may develop the need for ' modifying the normal operating,maintenance and processing procedures. > Failure of commercial(prime)power; > Storms; > Explosions; > Fires; ' > Hydraulic overloading,ruptures and blockage; > Equipment breakdown and process failures; > Spills of oil,toxic or hazardous materials into sewers or at the treatment works; and, > Personnel injury. Some of these situations can also produce additional emergency situations requiring decisions which will have to be assigned on a priority basis;i.e.,a storm could directly create or cause(1)failure of commercial power to treatment plant and pumping station: (2)flooding conditions;(3)failure of the alarm system;(4) personnel injuries;and(5)hazardous transportation conditions for maintenance and operating personnel,repair of equipment or removal of injured. The listed situations are analyzed in detail through out the remainder of this section. ■ ' Failure of Commercial (Primary) Power Partial or complete loss of primary power to motors,controls,alarms and reporting ' systems at the wastewater treatment plant can result in a complete inability to transfer the raw sewage through the treatment facility and impairment of the ' efficiency of the sewage processing and handling. All components of the treatment plant and exterior pumps are connected to an emergency generator equipped with an automatic power transfer switch. In the event of a power failure all essential equipment will automatically resume operating. The pattern of response will be influenced by the extent and the duration of the ' electrical failure. The longer a power failure continues the greater the extent of the corrective and notification activities. The severity of the power failure will be dependent upon the time of the year,cause of the loss of power and estimated time ' that power will be off. M\LD\05162\Dms\Memos\W astewater ' Treatment\Cotui O&M2_VHBformat 24 Emergency Operations and Response B Vanasse Hangen Brustlin,Inc. In the event of a power failure the operator should immediately notify the Plant ' Chief Operator,the plant electrician and the electric utility company. The operator should not attempt to correct an electrical problem on his own,but should wait until experienced electrical personnel arrive on the scene and allow them to take corrective ' action. After restoration of the primary power supply,normal operation of the plant shall be ' resumed by a manual start-up of the equipment which was not operational during the power loss. Some equipment will restart automatically when power is returned. Storms In addition to disruption of the primary electric power and possible flooding ' damage,storms can result in felled trees,broken branches or downed utility poles which may disrupt the alarm reporting system or telephone communications,stop or greatly hamper movement of personnel and increase the problems of restoring operations. ' > An assessment of severity of other effects will depend upon the character of the damages as they affect the sewer system operation. > Rupture of water distribution lines which can become polluted is of prime importance. ' > Felled trees,branches,electric or telephone poles which will hinder or stop travel required for repair are of secondary importance. ' > Damaged buildings and structures take third priority. > Hazards such as washouts,holes in the road,and impassable areas where ' pavement has been destroyed,are of lesser importance. In the event of fallen trees,telephone poles and the like,the operator should immediately notify the Police,Fire and Highway Departments and the affected utility company. Fallen trees,branches,poles and the like will be the responsibility of the Owner and the Power and Telephone Companies. All power lines should be ' treated as being"live"and should only be handled by the utility companies. Trees or branches held up by electric wires should be moved only in extreme emergency and, if moved,extreme care should be exercised to avoid collapse,which may cause fires ' or electrocution. M M051620D sWemosMastewater Treaiment\Cotu1 O&M 2_VHBtormat 25 Emergency Operations and Response ' IM Vanasse Hangen Brustlin,Inc. ' Explosions Explosions can result from ignition of accumulated dusts,sewer or petroleum gases. ' Explosions may occur in pump chambers,wet wells,sewer manholes,large trunk sewers,chemical rooms,or laboratories. Explosions may disrupt power,cause flooding or damage sewers,structures or other equipment and may be accompanied by fire. A brief investigation of the explosion should be made. The fire department shall be notified immediately,telling them the nature and location of the mishap and whether or not any personnel have been injured. An explosion with accompanying fire will probably create structural damage,disrupt electrical circuits and damage pumps and ' piping. Any fire should be contained,if possible,using the fire extinguisher or by closing all entrances to the area. Electrical power and water flow to the area should be shut off from outside the affected area. If structural damage has occurred,do not enter the facility,but rather make an examination from the exterior through windows and doors. Determination of the ' soundness of the structure should be made by a structural engineer. If damage is not apparent,the structure may be entered for assessment of damage to equipment, pumps,piping or electrical system and the shut-down of affected systems. The first entrance should be made cautiously and preferably after the fire department has arrived. ' An explosion in a manhole or sewer will expend itself upward by blowing off the manhole cover and through the connecting pipes. Upon arriving at the scene,it should be determined if any damage has been done by the cover in flight. Also,the 1 manhole and piping should be checked for damage. Adjacent manholes should also be examined since some of the explosive pressure will pass through the pipes to these structures. After the immediate danger of the explosion has passed and any fire extinguished, the operator should implement the following plan: ' > Determine what pieces of equipment are available for processing and what PP g piping paths are available for handling the wastewater. Appropriate alterations ' in the normal process to continue or resume treatment. At all times,the safety of personnel and equipment shall be considered. ' > If pumping equipment or piping is damaged,flow may have to be rerouted through other pumping units not normally used for this purpose. If other pumps or equipment are not available,portable pumps and temporary piping may have to be employed. Breaks in pipelines should be isolated temporarily by closing valves and repaired as soon as possible. M\LD\05162\Doos\Memos\W aslemter Treatment\Cotuit O&M 2_VH8forma1 26 Emergency Operations and Response i ' VB Vanasse Hangen Brustlin,Inc. > Clean up all sewage,oil,gasoline and chemical spills immediately and vent the area against an accumulation of explosive vapors. ' > Damaged electrical equipment,switches and controls should be temporarily by-passed or taken out of service completely and replaced at the earliest convenience. ' > If a cubicle or section of a motor control center is damaged,locate if possible,an undamaged plug-in unit which services a nonessential piece of equipment and make the connections to that unit,until the damaged unit is repaired or replaced. > Damage to instrumentation units will necessitate replacement of the units. 1 Operation will have to be continued until repairs or replacements are made. Manual measurements of essential parameters should be made wherever practical. > Wiring circuits that are damaged must be replaced immediately,before connections can be made to new or repaired parts. No structural damage should be considered minor until it has been inspected by professionals. The building inspector should be notified as soon as possible and ' professionals hired to make temporary and permanent repairs. The affected areas should be closed off until after an inspection has been completed by persons experienced in this field and any temporary repairs have been made. Areas adjacent ' to the affected areas should be covered with tarpaulins to prevent damage to equipment,instruments and records by inclement weather,spillage,broken pipes and the like. ' Manhole or pipeline explosions will constitute a minor emergency. Portable pumps and temporary piping may have to be employed during repair operations. Damaged manholes shall be repaired as quickly as possible. Paved inverts can be restored by blocking incoming lines and setting brick with hydraulic cement or other quick setting compounds. If regular cement is used,it can be protected by using a length of ' stove-pipe or similar material for temporarily carrying sewage through the manhole and sealing the annular spaces at the pipes. Cracks in the walls can be sealed using hydraulic cement. Displaced frames should be reset. ' Fires Fires at the treatment facility will typically be of wastepaper,oily cloths or electrical types and may also be the result of explosions,spontaneous combustion,smoking or arson. All structures have been built to be fire resistant,comprised of as little combustible material as possible. Fire extinguishers,dry-chemical,types A,B or C are installed within the Stop&Shop building. M\LD\05I62\Dms\Memos\W astemter Treatment\C00 O&M 2_VHBto—at 27 Emergency Operations and Response i B Vanasse Hangen Brustlin,Inc. Determination of the extent of damage caused by the fire to equipment,such as motors,controls,instruments and circuits is of primary importance. The investigation of the cause of the fire is of secondary importance. The severity of the ' fire will depend on the damage done to essential items of equipment. In the event of fire,the operator should immediately notify the Fire Department and ' the Owner. Prevention of fire damage is of utmost importance and can be accomplished by carefully adhering to the following: > Empty wastebaskets daily. > Clean up all oil and chemical spills immediately and completely. > Dispose all oily,greasy or paint cloths after each use by putting them in airtight, fireproof metal containers. > Check all oil,fuel and gasoline drips and repair leaks immediately. > Know where all fire extinguishers are located,which ones to use for which type ' of fire,and how to use them. > Check extinguishers semiannually and have them recharged annually. If present when a fire starts,move immediately to the nearest exit door. A fire extinguisher is mounted near the door. Activate the appropriate extinguisher and try ' to put out the fire keeping between the fire and the exit. If the fire cannot be put out with one extinguisher,retreat towards a telephone,shutting all doors along the way. ■ Hydraulic Overloads, Ruptures and Blockage ' Hydraulic overloads may be caused by water entering the sewers through broken pipes,flooded manholes or leaking joints. Hydraulic overloads may the result of floods,hurricanes,severe storms or infiltration due to high ground water conditions. Ruptures may result from flooding,earthquakes or explosions. Blockage may generally result from the deposition of foreign material in manholes,leaking pipes, accumulation of solids in sewers which have"flat"slopes or pipeline breaks. Hydraulic overloads will be marked b unusual increases in the flow characteristics Y Y as recorded by the flow meters. Ruptures will be indicated by an increase or ' decrease in flow to the treatment plant. Blockage will result in backing up sewage in the lines above the point of stoppage resulting in the leaking of sewage at manhole M\LD\05162\Dots\Memos\W aste—ter ' Treatment\Cotuit O&M 2_VHBlormat 28 Emergency Operations and Response ' VB Vanasse Hangen Brustlin,Inc. covers or where watertight covers exist,sewage entering adjacent structures through service connections. ■ ' Equipment Breakdowns and Process Failures All components of the treatment facility are connected to a central alarm system in ' the Equipment Control Panel. Should an equipment failure or overload occur,an alarm light and horn mounted on the underground vault building will be actuated. Upon discovering an equipment failure,the operator shall immediately make the necessary arrangements to replace or repair the failed unit. The failure of major equipment requires the prompt notification of the Department of Environmental ' Protection,Division of Water Pollution Control,Southeast Regional Office in Lakeville. Breakdown of essential equipment,such as pumps,aeration facilities and settling tanks,could endanger the entire treatment operation. Duplicate units have been provided for most of the essential equipment such as pumps and air compressors; ' however,failure of any piece of equipment may result in a partial failure of the treatment process,which will necessitate process adjustments,and may also result in a loss of time and costly repairs. ' Overloading of the equipment will initiate audible and visual alarms in the instrumentation panel. As soon as an alarm is sounded and the location of the ' emergency is displayed on the equipment control panel, the operator should investigate and determine the cause and extent of the emergency. This investigation should minimize the possibility of permanent damage to equipment,flooding or ' injury to personnel. If the failure is electrical in nature and is not the result of primary power source ' failure,the switch handle on the motor control center for that piece of equipment should be shut off,the reset button pushed and the handle set to"ON". If the unit fails to run,the standby unit should be made the lead unit. The unit that failed ' should be disconnected and checked out by the plant electrician. When any major piece of mechanical equipment fails,the standby unit should be ' placed in operation prior to investigating the failure. Surety of the standby unit's operation must be ascertained prior to working on the failed unit to ensure continuation of the process. The failed unit should then be checked carefully to ' pinpoint the cause of the failure. Any part that is damaged should be replaced from the parts inventory of the equipment supplier. Spare parts should be stocked as recommended by the manufacturer and an inventory maintained. New parts should ' be ordered to replaced those used for repair. M M05162\Doos\Memos\Wasfew ler ' Treatment\Oofuh O&M 2_VHBfoonaf 29 Emergency Operations and Response ' VB Vanasse Hangen Brustlin,Inc. Normally,process failures can be attributed to equipment failure,elimination of ' some feature of the treatment process or may result from oils,acid,bases or toxic wastes in the influent. The presence of these materials will generally be caused by accidental spills or illegal discharges. The appropriate emergency action necessary to ' correct the situation is covered under the section entitled"Spills of Oils,Acids,Toxic or Hazardous Materials." All electrical equipment is equipped with thermal overload protection which trips at the appropriate motor starter in motor control centers or individual motor starters. ■ Spills of Oils,Acids,Toxic or Hazardous Materials Spills of oil,acids,toxic or hazardous materials into the treatment works or the sewer system may be deliberate or the result of an accident with spillage entering the sewer system through manhole covers or service connections. Deliberate spills of deleterious materials into the sewer system are not likely to be discovered until they appear at the treatment facility and interfere with the treatment ' process.Generally,accidental spills will not be known until evidence of the accident reaches the treatment facility. Spills at the treatment facility by plant personnel are usually known,enabling corrective measures to be initiated immediately. When a spill results from an accident on city or state roads where sewer lines are installed,the Fire Department or others will usually be called to clean up the spill. In some instances they may inadvertently flush the oil,gasoline or other materials down the storm drainage system. Some of this flushing may also enter the sanitary plant as a consequence of flushing. ' The operator will be responsible for ensuring that corrective measures are undertaken. The operator should coordinate actions by the Police and Fire ' departments,and the Department of Public Works. Liquid spills shall be flushed heavily down the sewer line to reduce their ' concentration. Acids or bases will have their concentrations reduced by the flushing operation. Powdered substances should be flushed to the next manhole. The outlet side of the ' downstream manhole should be to prevent the material from reaching plugged P S pumping stations or the treatment plant. The manhole should be pumped out and ' the material properly disposed of. M M\LD\05162\Dws\Memos\Was1ewater ' Trealment\Cotuit O&M 2_VHBtormat 30 Emergency Operations and Response ' WB Vanasse Hangen Brustlin,Inc. ■ ' Personnel Injury Personnel injury can result from falls,from working in tight places,cuts,abrasions or ' broken bones resulting from improper use of tools,being overcome by gas,electrical shock,carelessness,slipping into tanks or manholes and during plant emergencies. The operator should immediately call a physician,ambulance service,Police or Fire Department and the Owner. ' Personnel should have available and be familiar with a copy of a first aid manual such as is published by"The American Red Cross." Cleanliness,proper maintenance,correct operating procedures,a team approach to work in remote or hazardous areas,and properly coordinated safety programs are the main ways of minimizing the risk of personnel injuries. Emergency Readiness Program ■ Emergency Telephone Numbers A list of emergency telephone numbers should be completed and posted in a ' conspicuous location in the underground utility vault. The plant operator should be given the responsibility for maintaining the accuracy of the list. Copies of the list should also be kept with the treatment plant operator and with the Owner. This list ' should be checked periodically for accuracy and changes made to all posted lists. ■ ' Emergency Equipment Inventory An inventory should be made of equipment,materials and chemicals available_at the ' treatment facility which can be used in case of an emergency. Any additional emergency equipment and supplies required should be,purchased and stockpiled or arrangements made to obtain these items through outside contracts. ■ ' Treatment Facility Records A program should be established for the protection of essential records,plans and reports.All originals should be stored in the Store Management Office. These items ' must be available for immediate use and can be reproduced as required. M\LD\05162\Dms\Memos\Wastewa1er ' Treatment\Co1W O&M 2_VHBformat 31 Emergency Operations and Response B V anasse Hangen Brustlin,Inc. Coordination with Police and Fire Department Establish a program for local fire and police departments to periodically review the treatment plant for adequacy of fire prevention and security measures. These agencies should be made aware of any potential chemical emergencies. The treatment facility's emergency response action should be coordinated with the local Police and Fire departments. Coordinating instructions are outlined below and consideration should be given to the items in the following checklists: > Police Department Checklist Critique existing treatment facility security measures. Make routine checks of treatment facility. Notify treatment facility in the event of a street spill of hazardous materials. Be prepared to assist during emergencies at the treatment facility. > Fire Department Checklist Routinely check fire fighting equipment at the facility and inspect the plant for potential fire hazards. Provide first-aid instruction to treatment facility personnel. Coordinate with treatment facility personnel on safety precautions to be used with methanol gas. Y � M\LD\05162\Dots\Memos\Wastewa1er Treatment\Cotuit O&M 2_VHBtomat 32 Emergency Operations and Response IM Vanasse Hangen Brustlin,Inc. 9 Safety The first rule of any safety program is good housekeeping. Work areas should be well lighted. Service walkways and handrails should be inspected periodically to ensure they are in suitable condition and free of rust. Floors should be well swept and free of spills which may cause slipping. For safety reasons,the facility should have a fully stocked first-aid kit,complete with a sufficient supply of gauze, bandages,first-aid creams,disinfectants and eye-wash kit. An adequate supply of fully charged fire extinguishers should also be maintained at the facility in conspicuous locations. In addition to the proceeding,personal hygiene is of utmost importance when working around wastewater. It is advised that hands and fingers be kept away from .� the eyes,mouth,ears and nose to prevent the risk of infection. Gloves should be worn whenever cleaning or repairing equipment which is in contact with wastewater or when collecting wastewater samples. Any cuts or scratches received while working at the facility should be attended to immediately. As a further precaution, gloves should be worn when hands are chaffed,burned or when the skin has been broken. Noxious gases and vapors can present a serious hazard in wastewater treatment facilities and related appurtenances. Operating personnel should be thoroughly familiar with the characteristics,sources and means of testing for the common gases associated with sewage treatment facilities. Safe practice requires that,before entering any manhole,pump chamber or enclosed tank,tests should be conducted for the presence of dangerous gases. The chamber should be blown out with fresh air if there is any evidence of flammable or toxic gases. A hydrogen sulfide test kit is strongly recommended for use in testing the facility's pump chambers and recycle tank. As a further precaution,operating personnel should not enter any confined space unless accompanied by someone capable of providing assistance in the event of an accident. Should the plant operator be alone at the plant and the need to enter an underground tank or confined area presents itself,the operator should contact the chief operator so that a confined space entry permit may be obtained. Once the permit is obtained and signed by the chief operator,the confined space may be entered,but not without adhering to all OSHA confined space entry procedures. M\LD\05162\Dws\Memos\W astewater Treatment\Cotuit C&M 2_VHBfo"at 33 Safety I Vanasse Hangen Brustlin,Inc. Employee hazards in wastewater treatment facilities include exposure to: physical injuries,body infections, oxygen deficiency,noxious gases or vapors,etc. These occupational hazards are largely avoided by the execution of safe practices and the use of safety equipment. It is the responsibility of plant operators to acquaint themselves with the hazards associated with facilities maintenance and operation and to take steps to eliminate them. OSHA standards require the treatment plant operator to furnish safe tools, equipment,layout,and materials,and to define policies which will keep them properly maintained in safe working condition. In addition,a list of emergency telephone numbers and contacts should be available at all telephones. It is also the management's responsibility to select workers who are physically and mentally capable of performing the work required and possess the necessary aptitude for the specific tasks within the facilities. In addition,the management must provide adequate education and training in accepted safety procedures. Workers have a responsibility to themselves,their families,and their jobs to do everything they can to prevent personal injuries. This can be accomplished by conformance to established safety regulations and utilization of the proper safety �i. equipment in the performance of the daily work routine. Human error is the most significant cause of accidents and it is the employee's responsibility to perform his job safely. Development of a safety program is a necessity. The purpose of this safety program should be to define the principle under which the work within the plant is to be accomplished,and to make the employees of the plant aware of safe working procedures. Perhaps the most essential element of a good safety program is the incorporation of some form of safety training. The purpose of safety training is to convey the importance of safety to the employees at the plant. Safety training can be accomplished through safety manuals,safety meetings,safety posters placed in strategic areas in the plant,and a safety suggestion program. The overall danger of accidents are the same whether in manholes,pumping stations or treatment facilities. These hazards include: > Physical1 injuries; > Body infections; > Noxious gasses or vapors;and, > Oxygen deficiency. In many areas of the plant where sewage solids collect and are pumped,sludge gas may be produced. Sludge gases may contain toxic concentrations of hydrogen sulfide,which can cause death. Sludge gas may also contain explosive M\LD\05162\Dots\Memos\Wastewater ,. Treatment\Cotuit O&M 2_VHBtoona1 34 Safety VB Vanasse Hangen Brustlin,Inc. concentrations of methane. However,the most important point to remember is that areas that contain sludge gas are usually deficient in life-sustaining oxygen and are, therefore,the greatest hazard. In pump chambers,flammable vapors such as gasoline and solvents may be present. Gasoline vapor is heavier than air,and presents the hazards of asphyxiation and explosion. Such places should be provided with forced ventilation. All electrical switches,lights,motors and fixtures should be explosion proof,and smoking shall be prohibited. Ammonia,which is explosive and harmful to the respiratory tract and eyes,may be found in sewers or enclosed treatment facility areas. Solvent vapors,resulting from the discharge of gasoline,lubricating oils,benzene, naphtha and similar solvents and petroleum products,may cause suffocation or possibility of explosion. A safety training program should be instituted by the treatment plant operator to prevent injuries. Following is a list of some of the items which should be inco-porated in the safety program: > Employee training > Maintenance of safe working conditions > Medical and first aid > Accident record system > Accident investigation > Safety program: s a. storage facilities b. illumination c. ventilation d. fire control e. water supply f. safety facilities considerations g. personal hygiene { ; ➢ h. safety equipment i. good housekeeping j. oxygen deficiency �_ ➢ k. electrical safety 1. hazardous operations m. material handling n. ladder operations Safety equipment that shall be available to the operator is listed in Chapter 11 of this document. M\LD\05162\Does\Memos\Wastewa1er Treatment\CotuH O&M 2_VHBtonnat 35 Safety 117 B Vanasse Hangen Brustlin,Inc. 10 Utilities The following utilities provide service to the treatment plant and the adjoining complex: Electric- Commonwealth Electric Co. 484 Willow Street Hyannis,MA 02601 PH: (508)291-0905 FX: (508)790-9370 Telephone Verizon 44 Old Town House Road South Yarmouth,MA 02664 PH: (508)398-5714 FX: (508)394-1988 r i \ 1 ` r M\LD\05162\Dws\Memos\W aslemter Treatment\Cotuit O&M 2_VHBlorrnat 36 Utilities f B Vanasse Hangen Brustlin,Inc. q Supplies and Maintenance Schedule J Spare Parts and Supplies The following is a listing of spare parts and supplies that should be available to the plant operator for the maintenance and repair of the treatment plant and related appurtenances. Said components,especially electronics,must be stored in accordance with manufacturer's recommendations to ensure a stable shelf life. The quantities listed are the minimum that should be kept on hand at any one time. Safety Supplies > Three conductor grounded extension cord(50'long) > First-aid kit > Canvas work gloves > Rubber gloves and boots > Garden hose with nozzle(50'long) > Warning signs and tags > Hard hat > Fire extinguisher > Safety eye glasses > Oxygen deficiency detector > Explosive gas detector > Hydrogen sulfide detector > Ammonia detector > Rain gear and/or chemical suit > Volt meter or indicator > Speedy dry for spills(chemicals,polymer,lubricants,etc.) ~ Safety supplies are to be available to the treatment plant operator. R M\LD\05162\Dots\Memos\Was1ev ter Treatmem\Cotui:O&M 2_VHBformat 37 Supplies and Maintenance Schedule i ' vB Vanasse Hangen Brustlin,Inc. ■ Maintenance Schedule See the Zenon Maintenance Manual: lam. ` M\LD\05162\Doos\Memos\Wastewater i Treatment\Cotuit O&M 2_VHBlormat 38 Supplies and Maintenance Schedule VB Vanasse Hangen Brustlin,Inc. Telephone Index Treatment Plant Operator (Tentative) r Coastal Engineering Company 260 Cranberry Highway Orleans,MA 02653 PH: (508)255-6511 FX: (508)255-6700 Consulting Engineer Bryan Lynch,P.E. Vanasse Hangen Brustlin,Inc. 101 Walnut Street PO Box 9151 Watertown,MA 02471-9151 PH: (617)924-1770 FX: (617)924-2286 Waste Hauler (Tentative) Bousfield Sanitary/Bouse House Enterprises Route 28 Yarmouth,MA PH: (.508)398-1135 Solids Disposal Facility Yarmouth-Dennis Septage Treatment Facility Managed by AquaSource,Inc. V Workshop Road i M\LD\05162\Dots\Memos\Wastewater V Treatment\CotO O&M 2_VHBfonat 39 Telephone Index VILB Vanasse Hangen Brustlin,Inc. South Yarmouth,MA 02664 PH: (508)760-2414 FX: (508)760-2990 BackupSolids Disposal Facility p Y Massachusetts Environmental Services,Inc. 1 Meade Road PO Box 36 North Carver,MA 02355 � PH: (508)866-8140 FX: Testing Laboratory Envirotech Laboratories,Inc. 449 Route 130 Sandwich,MA 02563 PH: (800)339-6460 FX: General Contractor Kay Construction Corporation 49 Winchester Street P.O. Box 610307 Newton,MA 02461-0307 1 1 Equipment Suppliers ■ Zenon Units Zenon Municipal Systems,Inc. 3239 Dundas Street West Oakville,Ontario Canada LGM 4132 PH: (617)969-0606 FX: (617)969-0505 M\LO\051620 s\Memos\Wastemler Treatmenl\Cotuit O&M 2_VHBtormat 40 Telephone Index I11L7 Vanasse Hangen Brustlin,Inc. Pump Station Pumps and Controls(Tentative) Kay Construction Corporation 49 Winchester Street P.O.Box 610307 �l Newton,MA 02461-0307 PH: (617)969-0606 FX: (617)969-0505 Local Medical Facilities Cape Cod Hospital 27 Park Street Hyannis,MA PH: (508)771-1800 FX: Utilities Dig Safe 1-888-DIG-SAFE (1-888-344-7233) ■ Electric N-Star 484 Willow Street Hyannis,MA 02601 i PH: (508)291-0950 FX: (508)790-9370 1 ■ Gas Keyspan Energy Delivery �} 40 Market Street Lowell,MA Billing,Service,and Leaks: (800)548-8000 1 M\LD\05162\Does\Memos\Wastewater Treatment\CoW O&M 2_VHBformat 41 Telephone Index / VB Vanasse Hangen Brustlin,Inc. ■ Telephone Verizon 44 Old Town House Road ` South Yarmouth,MA 02664 PH: (508)398-5714 FX: (508)394-1988 1-800-870-9999 ■ Water Centerville,Osterville, Marston Mills Water District � 1-508-428-6691 Reporting Department of Environmental Protection Division of Water Pollution Control Southeast Regional Office 20 Riverside Drive Lakeville,Massachusetts PH: (508)946-2714 FX: (508)947-6557 Department of Environmental Protection Division of Water Pollution Control One Winter Street Boston,Massachusetts 02108 PH: (617)292-5500 FX: (617)292-5696 DEP Emergency Response Monday through Friday(9:00 AM to 5:00 PM) (978)661-6681 1 After Hours,Weekends,And Holidays (617)292-5500 Barnstable Board of Health 508-862-4644 h M\LD\061620ocs\Memos\Wastewater Treatment\CotuO O&M 2_VHBtonnat 42 Telephone Index I11U Vanasse Hangen Brustlin,Inc. Emergency Numbers (Emergency and Business) ■ Public Safety Emergency Business Ambulance 911 Barnstable Fire Department 911 (508)362-3312 Barnstable Police Department 911 State Police(Troop D-7SP 911 (508)759-4488 Barracks) MA Poison Information Center (800)682-9211 (800)682-9211 Hazmat(Chemical Spills) 911 (978)567-3150 RCRA (Hazardous Wastes) (800)424-9346 OSHA (617)727-3452 ■ DEP Emergency Response Monday through Friday(9:00 AM to 5:00 PM) (978)661-6681 After Hours,Weekends,And Holidays (617)292-5500 Operations ■ Facility (Tentative) Coastal Engineering Company 260 Cranberry Highway Orleans,MA 02653 PH: (508)255-6511 FX: (508)255-6700 ■ Owner Stop&Shop Supermarket Co. 1385 Hancock Street Quincy,Ma 02168 Attn: Walter Steinkrauss PH:617-770-7193 M\LD\05162\D0es\Memos\Was1ewater Treatment\CotuR O&M 2_VHBfom l 43 Telephone Index Vanasse Hangen Brustlin,Inc. Appendices �1 > Appendix A DEP Permit > Appendix B Reporting Forms-Pending > Appendix C Operating Contracts -Sample attached > Appendix D Zenon System-Design Catalog(Separate Report) > Appendix E Control Diagrams and Pump Stations(Separately Bound Drawings) �1 1 � M\LM051620m MemosMastewater TreatmenhCotuit O&M 2_VHBforma1 Appendices Vanasse Hangen Brustlin,Inc. Appendix A: DEP Permit ' M\LD\051 62\Dm Memos\Wastewater Treatment\Cotull OBM 2_VHBformat Appendix A: DEP Permit o�/CZ COMMONWEALTH OF MASSACHUSETTS Z F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 11 _ , d DEPARTMENT OF ENVIRONMENTAL PROTECTION 20 RIVERSIDE DRIVE, LAKEVILLE, MA 02347 308-946-2700 e JANE SWIFT BOB DURAND Governor Secretary LAUREN A.LISS Commissioner September 24,2001 Walter Steinkrauss RE: BARNSTABLE: Cotuit Landing Stop & Shop Supermarket, Co. Shopping Center, 3860 Falmouth Road. 1385 Hancock Street Permit No.: SE 0-728 Quincy, Massachusetts 02168 Transmittal No. W020667 Dear Mr. Steinkrauss: The Massachusetts Clean Water Act(M.G.L. c.21, s.21-53)was amended by Chapter 246 of the Acts of 1973 to authorize the Department to regulate discharges into,all waters of the . Commonwealth, including groundwaters. The Department regulates discharges through the issuance of discharge permits,which impose limitations on the amount of pollutants that may be discharged in the effluent, together with monitoring and reporting requirements and other conditions to insure adequate treatment of all liquid wastes prior to discharge. The Department has reviewed your application for a permit to discharge treated wastewater to the ground to be located at the Cotuit Landing Shopping Center, and has developed the conditions contained in the enclosed draft permit. Within fourteen(14)days of receipt of the draft permit,you should indicate to this agency in writing either the acceptability of the permit conditions or any problem areas. Any discharge not authorized by or in violation of the terms of the permit is in violation of State Law and subject to civil or criminal penalties. The proposed permit can only be considered in draft form because of provisions in the Law regulating public notice of the proposed issuance of the permit and opportunity for public comments and public hearing. A public notice will be sent to you once the Department has received your acceptance of the draft permit. Following publication and receipt of comments on the public notice and public hearing, if necessary, a final determination to issue or deny the permit will be made. If you should have any questions or would like to discuss the draft permit,please contact Christos Dimisioris at(508) 946-2736. Very truly yours Van`CniA. Dudley Bureau of Resource otection D/CD/bh This information is available in alternate format by calling our ADA Coordinator at(617)574-6872. DEP on the World Wide Web: http://www.magnetstate.ma.us/dep ��. La Printed on Recycled Paper r 2 Enclosure cc: Board of Health P.O.Box 534 Hyannis,MA 02601 Brian F.Lynch,P.E. yi Vanasse Hangen Brustlin,Inc. 101 Walnut Street,P.O.Box 9151 Watertown,MA 02471 DEP-Boston ATTN: Wastewater Management . r- ,r r . . GROUNDWATER DISCHARGE PERNUT Name and Address of Applicant: Stop & Shop Supermarket Co., 1385 Hancock Street, Quincy,Massachusetts 07168. Date of Application: July 25,2001 Application/Permit No. 728=0 Date of Issuance: DRAFT Date of Expiration: DRAFT Effective Date: DRAFT AUTHORITY FOR ISSUANCE Pursuant to autho-ity granted by Chapter 21, Sections 26-53 of the Massachusetts General Laws, as amended,the following permit hereby issued to: Stop & Shop Supermarket Co. (hereinafter called "the permittee") authorizing discharges from the Cotuit Landing Shopping Center, 3860 Falmouth Road, Barnstable, MA 02648 on-site wastewater treatment facility to the rground, such authorization being expressly conditional on compliance by the pennittee with all terms and conditions of the permit hereinafter set forth. DRAFT DRAFT Brian A.Dudley Date Bureau of Resource Protection DRAFT 2 - . I. SPECIAL CONDITIONS A. Effluent Limits The permittee is authorized to discharge into the ground from the wastewater treatment facilities for which this permit is issued a treated effluent whose characteristics shall not exceed the following values within one month of startup and continuing thereafter: Effluent Characteristics Discharge Limitations Flow 21,600 GPD Oil and grease 15 mg/1 Total Suspended Solids (TSS) 30 mg/l Total Nitrogen(NO2+NO3 +TKN) 10 mg/l Nitrate-Nitrogen 10 mg/l g/1 Biochemical Oxygen Demand, 5-day @20°C 30 mg/l (BOD5) a) The pH of the effluent shall not be less than.6.5 nor greater than 8.5 at any time or not more than 0.2 standard units outside the naturally occurring range. b) The discharge of the effluent shall not result in any demonstrable adverse effect on the groundwater or violate any water quality standards that have been promulgated. c) The monthly average concentration of BOD and TSS in the discharge shall not exceed 15 percent of the monthly average concentrations of BOD and TSS in the influent into the permittee's wastewater treatment facility. d) When the effluent discharged for a period of 90 consecutive days exceeds 80 percent of the permitted flow limitations, the permittee shall submit to the permitting authorities projected loadings and a program for maintaining satisfactory treatment levels consistent with approved water quality management plans. DRAFT i 3 - B. Monitoring and Reporting 1) INFLUENT: The permittee shall monitor and record the quality of the influent waste stream to the facility according to the following schedule and other provisions: Parameter Minimum Frequency of Sample Type Analysis pH Daily Grab BOD5 Monthly 12-Hour Composite Total Suspended Solids Monthly 12-Hour Composite Total Solids Monthly 12-Hour Composite Oil and grease Monthly Grab Ammonia Nitrogen Monthly 12-Hour Composite Nitrite Nitrogen Monthly 12-Hour Composite Nitrate Nitrogen Monthly 12-Hour Composite Total Kjeldahl Nitrogen Monthly 12-Hour Composite (TK s Total Nitrogen(NO2+ Monthly 12-Hour Composite NO3 +TKN) Volatile Organic Annually Grab Compounds' USEPA Method#624 DRAFT 4 . EFFLUENT: - The permittee shall monitor and record the quality and quantity of effluent at the effluent pump chamber to the leaching area according to the following schedule and other provisions: Parameter Minimum Frequency Sample Type of Analysis Flow Daily Max-Min-Average pH Daily Grab Total Suspended Solids Monthly 12-Hour Composite Total Solids Monthly P 12-Hour Composite Chlorides Monthly Grab Oil & Grease Monthly Grab BOD Monthly 12-Hour Composite s Y P Ammonia Nitrogen : Monthly 12-Hour Composite Total Kjeldahl Nitrogen Monthly 12-Hour Composite (TKN) Nitrite Nitrogen Monthly 12-Hour Composite Nitrate Nitrogen Monthly 12-Hour Composite Total Nitrogen(NO2+ Monthly 12-Hour Composite NO3 +TKN) Volatile Organic Annually Grab Compoundsi iUSEPA Method#624 2) The permittee shall install a minimum of three (3))monitoring wells, one upgradient and 2 downgradient of the discharge. Detailed plans of the wells,the locations thereof and the method and means of sampling therefrom shall be submitted to and approved by the DRAFT - 5 - Department prior to issuance of the permit. The permittee shall install the approved monitoring wells prior to startup of the facility and shall monitor,record and report the quality of water in the monitoring wells according to the following schedule and other provisions: Parameter Frequency of Analysis Static Water Level Quarterly Specific Conductance Quarterly TT pH Quarterly Total Nitrogen(NO2+NO3+TW Quarterly Nitrate-Nitrogen Quarterly Volatile Organic Com oundsl Annually g P Y IUSEPA Method#624 3) Any grab sample or composite sample required to be taken less frequently than daily shall be taken during the period of Monday through Friday inclusive. All composite samples shall be taken over the operating day. The permittee shall submit all monitoring reports within 30 days of the last day of the reporting month. Reports shall be on an acceptable form, properly filled and signed and shall be sent to the Department of Environmental Protection, Southeast Regional Office,20 Riverside Drive,Lakeville, MA 02347, and to the Director of Watershed Permitting, Department of Environmental Protection,Watershed Permitting Group, One Winter Street,Boston,MA 02108, and to the Board of Health, P.O. Box 534,Hyannis,'MA 02601. C. Supplemental Conditions 1) The permittee shall notify the Department at least thirty (30) days in advance of the proposed transfer of ownership of the treatment works for which this permit is written. Said notification shall include a written agreement between the existing and new permittees containing a specific date for transfer of permit,responsibility,-coverage and liability between them. DRAFT 6 — 2 A staffingplan for the treatment works shall be submitted to the Department once P P every two years or whenever there are staffing changes. erm 3) The permittee shall contract to have any and all solids and sludges generated b Y the P g g treatment works for which this permit is issued removed off site by a properly licensed waste hauler for disposal at an EPA/DEP approved facility. The name and license number of the hauler along with the quantity of wastes removed and the date(s) of removal shall be reported by the permittee in writing to the Department. 4 The facilityshall maintain!a security amount in the sum of at least 50 t ty $ ,000 o serve as a source of funding for the immediate replacement and/or repair of any failing wastewater treatment facilities. Such security shall be provided by means.of an interest-bearing escrow account and/or letter of credit with a standby trust agreement in a form satisfactory to the Department to fund the account. The permittee and/or its successors shall maintain the amount thereof in full within one year of any disbursement. The permittee on January 31 of each year give notice to the Department with evidence of the existence and continuing accessibility of the fund. 5) The facility shall establish and maintain a capital reserve account in order to accumulate sufficient capital to replace the wastewater treatment facility and other related equipment within 20 years from the date of commencement of plant operations. The permittee shall make annual contributions in equal installments in the amount of$19,500 to the account in order to accumulate the necessary funds within the 20-year period. Such funding shall be provided by means of an interest bearing account and/or letter of credit with a standby trust_agreement in a form satisfactory to the Department to fund the account. 6) Permittees must submit an annual financial report prepared in accordance with generally accepted accounting principles to the Department that includes: a. aggregate balance of the security funds; b. statement of all disbursements from the security funds, together with a description of the means by which the security funds will be replenished; C. all expenses for operation,maintenance, replacement or repair of the sewage treatment facility within the past year; d. all revenue generated to meet such expenses; e. projected means of accumulating sufficient capital (capital reserve account)to replace the sewage treatment facility by the year 2021 and proof that such sums are-being accumulated; and, f. initial and current balances in the capital reserve account and any other accounts. DRAFT ----------- 7 _ D. Appeal Rights PP g This Permit is an action of the Department. Any person aggrieved by this action may request an Adjudicatory Hearing. A request for a hearing must be made in writing and postmarked within thirty(30) days of the Permit issuance date. Under 310 CMR 1.01(6)(b),the request must state clearly and concisely the facts,which are the grounds for the request, and the relief sought. The Hearing request along with a'valid.check payable to the Commonwealth of Massachusetts in the amount of one hundred dollars($100.00)must be mailed to: Commonwealth of Massachusetts Department of Environmental Protection P.O. Box 4062 Boston,MA 02211 The request will be dismissed if the filing fee is not paid, unless the appellant is exempt or granted a waiver as described below. The filing fee is not required if the appellant is a city or town(or municipal agency), county, or district of the Commonwealth of Massachusetts, or a municipal housing authority. The Department may waive the adjudicatory hearing filing fee for a person who shows that paying the fee will create an undue financial hardship. A person seeking a waiver must file,together with the hearing request as provided above, an affidavit setting forth the facts believed to support the claim of undue financial hardship II. GENERAL PERMIT CONDITIONS The following conditions apply to all permits: 1. No discharge authorized in the permit shall result in a violation of the Massachusetts Surface Water Quality Standards (314 CMR 4.00) or the Massachusetts Ground Water Quality Standards (314 CMR 6.00), or any amendments thereto. Upon promulgation of any amended standards, this permit may be revised or amended in accordance with such ' standard and 314 CIVIR 2.10 and 3.12 or 5.12. For purposes of determining compliance with ground water quality standards, a violation of the ground water quality standards, and the discharge permit, will be determined to occur when any parameter measured in any downgradient well exceeds the applicable criteria listed in 314 CMR 6.06. In those cases where it is shown that a measured parameter exceeds the applicable criteria listed in 314 CMR 6.06 at the upgradient monitoring well, a violation of the ground water quality standards and the discharge permit will be determined to occur when it is shown that a measured parameter in any downgradient well exceeds the level of that same measured parameter in the upgradient well for the same sampling period. A statistical procedure approved by the Director shall be used in determining when a measured parameter exceeds the allowable level. DRAFT ............ ........... 8 - 2. Duty to comply. The permittee shall comply at all times with the terms and conditions of the permit, 314 CMR, M.G.L. c. 21, §§26 through 53 and all other applicable state and federal statutes and regulations. 3. Standards andprohibitions for toxic pollutants. The permittee shall comply with effluent standards or prohibitions established under PL 92-500 § 307(a) for toxic pollutants within the time provided in the regulations that establish these standards or prohibitions, even if the permit has not yet been modified to incorporate the requirement. 4. Proper operation and maintenance. The permittee shall at all times properly operate and maintain all facilities and equipment installed or used to achieve compliance with the terms and conditions of the permit, and in accordance with 314 CMR 12.00. 5. Duty to halt or reduce activity. Upon reduction, loss, or failure of the treatment facility, the permittee shall, to the extent necessary to maintain compliance with its permit, control production or discharges or both until the facility is restored or an alternative method of treatment is provided. It shall not be a defense for a permittee in an enforcement action that it would have been necessary to halt or reduce the permitted activity in order to maintain compliance with the conditions of the permit. 6. Power Failure.In order to maintain compliance with the effluent limitations and prohibitions of this permit, the permittee shall either: (a) provide an alternative power source sufficient to operate the wastewater control facilities; or (b) halt, reduce or otherwise control production and/or all discharges upon the reduction, loss, or failure of the primary source of power to the wastewater control facilities. 7. Duty to mitigate. The permittee shall take all reasonable steps to minimize or prevent any adverse impact on human health or the environment resulting from non- compliance with the permit. 8. Duty to provide information. The permittee shall furnish to the Department within a reasonable time any information which the Department may request to determine whether cause exists for modifying, revoking and reissuing, or terminating the permit, or to determine whether the permittee is complying with the terms and conditions of the permit. 9. Inspection and.entry. The permittee shall allow the.Department or its authorized representatives to: DRAFT . .... . . ... . ..... ............. ............ ........ ... 1 9 - a Enter upon the ermittee's remises where a regulated facility or activity is located ( ) P P P � tY ty or conducted, or where records required by the permit are kept; (b) Have access to and copy, at reasonable times, any records that must be kept under the conditions of the permit; (c) Inspect at reasonable times any facilities, equipment, practices, or operations regulated or required under the permit; and (d) Sample or monitor'at reasonable times for the purpose of determining compliance with the terms and'conditions of the permit. I 10. Monitoring. Samples and measurements taken for the purpose of monitoring shall be representative of the monitored activity. Monitoring must be conducted according to test procedures approved under 40 CFR Part 136 unless other test procedures are specified in the permit. 11. Record keeping. The permittee shall retain records of all monitoring information including all calibration and maintenance records and all original strip chart recordings for continuous monitoring instrumentation, copies of all reports required by the permit, and all records of all data used to complete the application for the permit, for a period of at least three (3)years from the date of the sample, measurement, report or application. This period may be extended by request of the Department at any time. Records of monitoring information shall include: (a) The date, exact place, and time of sampling or measurements; (b) The individual(s)who performed the sampling or measurement; (c) The date(s) analyses were performed; (d) The individual(s)who performed the analysis; (e) The analytical techniques or methods used; and (f) The results of such analyses. 12. Prohibition of bypassing. Except as provided in 314 CMR 5.19(13)� bypassing is prohibited and the Department may take enforcement action against a permittee for bypassing, unless the discharge.is to a surface water and: (a) The bypass was unavoidable to prevent loss of life,personal injury, or severe property damage; (b) There were no feasible alternatives to the bypass, such as the use of auxiliary treatment facilities,retention or untreated wastes, or maintenance during normal periods of equipment downtime. This condition is not satisfied if the permittee could have installed adequate backup equipment to prevent a bypass which occurred during normal periods of equipment downtime or preventive maintenance; and (c) The permittee submitted notice of the bypass to the Department: DRAFT - 10 - 1. In the event of an anticipated bypass at least ten(10) days in advance, if possible; or 2. In the event of an unanticipated bypass as soon as the permittee has knowledge of the bypass and no later than twenty-four(24) hours after its first occurrence. 3. Bypass not exceeding limitations. The permittee may allow a bypass to occur which 1 YP � p Y YP does not cause effluent limitations to be exceeded,but only if necessary for the performance of essential maintenance or to assure efficient operation of treatment facilities. 14. Permit actions. The permit may be modified, suspended, or revoked for cause. The filing of a request by the permittee for a permit modification,re-issuance, or termination, or a notification of planned changes or anticipated non-compliance does not stay any permit conditions. 15. Duty to reapply. If the permittee wishes to continue an activity regulated by the permit after the expiration date of the permit, the permittee must apply for and obtain a new permit. The permittee shall submit a new application at least one hundred.and eighty (180) days before the expiration date of the existing permit, unless permission for a later date has been granted by the Department. 16. Property rights. The permit does not convey any property rights of any sort or any exclusive privilege. 17. Other laws. The issuance of a permit does not authorize any injury to persons or property or invasion of other private rights, nor does it relieve the permittee of its obligation to comply with any other applicable Federal, State and local laws and regulations. 18. Oil and hazardous substance liability. Nothing in the permit shall be construed to preclude the institution of any legal action or relieve the permittee from any responsibilities, liabilities, or penalties to which the permittee is or may be subject under PL 92-500, § 311, and M.G.L. c.21E. 19. Removed substances. Solids, sludges, filter backwash, or other pollutants removed in the course of treatment or control of wastewaters shall be disposed in a manner consistent with applicable Federal and State laws and regulations including, but not limited to,the Massachusetts Clean Waters Act, M.G.L. c. 21, §§ 26 through 53 and the Clean Water Act, PL 92-500, as amended by PL 95-217 and PL 95-576, 33 U.S.C. 1251 et seq.,the Massachusetts Hazardous Waste Management Act,M.G.L. c.21C, and the federal Resource Conservation and Recover Act, 42 U.S.C. § 6901, et seq., 310 CMR 19.00 and 30.000, and other applicable regulations. DRAFT 20. Reporting requirements: (a) Monitoring Reports. Monitoring results shall be reported on a Discharge Monitoring Report (DMR) at the intervals specified elsewhere in the permit. If the permittee monitors any pollutant more frequently than required by the permit,the results of this monitoring shall be included in the calculation and reporting of the data submitted in the DMR. (b) Compliance schedules. Reports of compliance or non-compliance with, or any progress reports on, interim and final requirements contained in any compliance schedule of the permit shall be submitted no later than fourteen(14) days following each schedule date. (c) Planned changes. The permittee shall give notice to the Department as soon as possible of any planned physical alterations or additions to the permitted facility or activity which could significantly change the nature or increase the quantity of pollutants discharged. Unless and until the permit is modified, any new or increased discharge in excess of permit limits or not specifically authorized by the permit constitutes a violation. (d) Anticipated non-compliance. The permittee shall give advance notice to the Department of any planned changes in the permitted facility or activity which may result.in non-compliance with permit requirements. (e) Twenty-four (24) hour reporting. The permittee shall report any non-compliance which may endanger health or the environment. Any information shall be provided orally within twenty-four (24) hours from the time the permittee becomes aware of the circumstances. A written submission shall also be provided within five (5) days of the time the permittee becomes aware of the circumstances. The written submission shall contain a description of the non-compliance, including exact dates and times, and if the non-compliance has not been corrected, the anticipated time it is anticipated to continue; and steps taken or planned to reduce, eliminate, and prevent reoccurrence of the non-compliance. The following shall be included as information, which must be reported within twenty-four(24) hours: 1. Any anticipated bypass which exceeds any effluent limitation in the permit. 2. Violation of a maximum daily discharge limitation for any of the pollutants listed by the Department in the permit to be reported within twenty-four(24)hours. Other non-compliance. The permittee shall report all instances of non-compliance (� p P P not reported under 314 CMR 3.19(20)(a), (b) or(e) at the time monitoring reports are submitted. The reports shall contain the information listed in 314 CMR 3.19(20)(e).. DRAFT 12 — rs must Toxics. All manufacturing, commercial, mining, or silvicultural dischargers(g) g g g . notify the Department as soon as they know or have reason to believe: 1. That any activity has occurred or will occur which would result in the discharge of any toxic pollutant listed in 314 CMR 3.16 which is not limited in the permit, if that discharge will exceed the highest of the following notification levels: a. One hundred micrograms per liter(100 µg/l); b. Two hundred micrograms per liter(200 4g/1) for acrolein and acrylonitrile; five hundred micrograms per liter(500 µg/1)for 2,4- dinitrophenol and for 2-methyl-4,6-dinitrophenol; and one milligram per liter 1 mg/1) for antimony; C. Five (5)times the maximum concentration value reported for that pollutant in the permit application; or 2. That they have begun or expect to begin to use or manufacture as an intermediate or final product or byproduct any toxic pollutant, which was not reported in the permit application. (h) Indirect discharges. All Publicly Owned Treatment Works shall provide adequate notice to the :Department of the following: g 1. Any new introduction of pollutants into the POTW from an indirect discharger which would be subject to PL 92-500,§§ 301 or 306 if it were directly discharging those pollutants; and 2. Any substantial change in the volume or character of pollutants being introduced into the POTW by a source introducing pollutants into the POTW at the time of issuance of the permit. 3. For purposes of 314 CMR 5.19, adequate notice shall include information on the quality and quantity of effluent introduced into the POTW, and any anticipated impact of the change on the quantity or quality of effluent to be discharged from the POTW. (i) Information. Where the permittee becomes aware that they failed to submit any relevant facts in a PP permit application, or submitted incorrect information in a P permit application or in any report to the Department,they shall promptly submit such facts or information: 21. Signatory requirement. All applications, reports, or information submitted to the Department shall be signed and certified in accordance with 314 CMR 3.14 and 5.14. 22. Severability. The provisions of the permit are severable, and if any provision of the permit, or the application of any provision of the permit to any circumstance, is held invalid, the application of such provision to other circumstances, and the remainder of the permit, shall not be affected thereby. DRAFT 13 - 23. Reo ener clause: The Department reserves the right to make appropriate revisions to the P P permit in order to establish any appropriate effluent limitations, schedules of compliance, or other provisions which may be authorized under the Massachusetts Clean Waters Act, M.G.L. c. 21, §§ 26 through 53 and the Clean Water Act, PL 92-500, as amended by PL 95-2i7 and PL 95-576, 33 U.S.C. 1251 et seq. in order to bring all discharges.into compliance with said statutes. 24. Approval of plans and specifications for treatment works. All discharges and associated treatment works authorized herein shall be consistent with the terms and conditions of this permit and the approved plans and specifications. Any modification to the approved treatment works shall require written approval of the Department. 25. Transfer of permits. (a) RCRA facilities. Any permit which authorized the operation of a RCRA facility which is subject to the requirements of 314 CMR 8.07 shall be valid only for the person to whom it is issued and may Y not be transferred. (b) Transfers by modification. Except as provided in 314 CMR 5.19(25)(a) and(c) a permit may be transferred by the permittee to a new owner or operator only if the permit has been modified or revoked and reissued or a minor modification made to identify the new permittee. (c) Automatic transfers. As an alternative to transfers under 314 CMR 5.19(25)(b), any permit may be automatically transferred to a new permittee if: 1. The current permittee notifies the Department at least thirty (30) days in advance of the proposed transfer date in 314 CMR 5.19(25)(c)2. 2. The notice includes a written agreement between the existing and new permittees containing a specific date for transfer of permit responsibility, coverage, and liability between them; and 3. The Department does not notify the existing permittee and the proposed new permittee of his intent to modify or revoke and reissue the permit. A modification under 314 CMR 5.19(25)(c)may also be a minor . modification. If this notice is not received, the transfer is effective on the date specified in the agreement mentioned in 314 CMR I19(25)(c)2. 26. Permit Fees. Any permittee, other than a public entity, required to obtain a surface water or ground water discharge permit pursuant to M.G.L. c. 21, §43 and 314 CMR 3.00 and 5.00, shall be required annually to obtain an inspection certificate from the Department, and submit the information and fee associated herewith in accordance with 314 CMR 2.12. Cotuit Landing.doc DRAFT vB Vanasse Hangen Brustlin,Inc. lid ■ Appendix B: Reporting Forms M\LD\05162\Does\Memos\Wastewater Treatmertt\OoWtl O&M 2_VHBfmmat Appendix B: Reporting Forms i DISCHARGE MONITORING REPORT FORM PERMIT No.: PROJECT: FACILITY: ' DATE SAMPLED: FILTER FEED PUMP CHAMBER/ PARAMETER INFLUENT PUMP CHAMBER CLEAR WELL EFFL. Flow(gpd) pH (pH units) BOD5(mg/L) c-BOD5(mg/L) TSS (mg/L) Nitrite-N (mg/L) Nitrate-N (mg/L) TKN (mg/L) Total Nitrogen (mg/L) Ammonia-N (mg/L) Alkalinity (mg/L) Oil &Grease (mg/L) Notes: vB Vanasse Hangen Brustlin,Inc. ■ Appendix C Operating Contracts M\LD\05162\Dots\Memos\Was1ewater Treatment\Cotuit O&M 2_VHBfo-at Appendix C: Operating Contracts OPERATION AND tMAINTENANCE SERVICES AGREEMENT I FOR SEWAGE DISPOSAL TREATMENT SYSTEM AT COTUIT LAN �DING DEVELOPMENT AND EXPANSION PROJECT BARr\STABLE, MASSACHUSETTS This agreement is made this - day of , 20_, by and between Stop and Shop Supermarket Companv, herein referred to as OWNER and herein referred to as OPERATOR, a corporation duly organized and existing under the laws of lk�lassachusetts and having its r p tncrpal place of business at In consideration of the mutual agreements herein contained, the parties hereto agree as follows: The OPERATOR ;i-tees to perform the following services regarding operation and mauuenance of the Zenon w;rstew:ucr treatment system at Stop & Shop Superm:uket. Barnstable, `'IA. The treatment system shall be operated by a Massachusetts Certified Wastewater Treatment Plant Oper:uicn in accordance with the requirements of 257 CMR 2.00 and the Board of Certification of O crat >ors of W� p ast�«atcr Treatment Plants. The treatment system shall also be operated in accordance with the conditions imposed by the Department of Environmental Protection. I• Operation and maintenance shall be performed to accordance with the Zenon manufacturers schedule A attached and as follows:: I. Check general condition/appearance of unit. �. Check for odor. 3. Check operating condition of equipment with the building pumps, controls, air blowers, filters, gaskets, etc. } 4. Check and characterize mixed liquor suspended solids 5. Open Tank cover and check dosing pumps operation, timing, and effluent clarity.. 6. Open valve manhole cover check general condition. ' 7. Check control box switches, alarms, timer, etc. 8. Complete and maintain service report file. B. Operations and maintenance records will be kept for each service visit and will be provided to owner on a monthly basis. . C. Monitorin, results will be forwarded to the Massachusetts D.E.P., the local health board, VNB, Inc. and the OWNER. D. In the event that the system alarm is activated or the system fails, the OWNER shall notify OPERATOR who shall notify the Department of Environmental Protection a. nd the Board of Health within 24 hours and corrective action measures will be taken ' immediately. II: COMPENSATION ' Cost for operation and maintenance services shall be S .annuall . y 111: PAYIMENT A payment deposit of S initiates services under this contract. Thereafter, monthly ' invoices will be approved to the OWNER by OPERATOR for services performed under PART I of this Agreement. The OWNER agrees to issue payment for all invoices within thirty (30) days of the date of issue. If any invoice remains unpaid after 30 days, interest charges will be assessed at the rate of 1-1/2 percent per month. Failure to provide payment within forty-five (45) days'of the date of issuance of any invoices will be cause for OPERATOR to stop providing services outlined in PART I of this Agreement. y - IV: TERM Services provided under Paragraph I will commence in accordance with the schedule from the date of this Agreement. The services shall be terminated two years from the date of this Agreement, at which time the continuing work, if necessary, shall be subject to a new contract for an additional time period. V: ADDITIONAL SERVICES It is further agreed that if OPERATOR is requested or is required to perform any services other than those outlined in PART I of this Agreement, OPERATOR shall receive additional compensation using the schedule set forth in PART II of this Agreement, but not without first receiving authorization in writing. y V: ADDITIONAL SERVICES It is further agreed that if OPERATOR is requested or is required to perform any services other than those outlined in PART I of this Agreement, OPERATOR shall receive additional compensation using the schedule set forth in PART II of this Agreement,but not without first receiving authorization in writing. VI: ACCESS TO SITE'RIGHT OF ENTRY 1. OWNER represents that all sampling ports are at ground level with access covers that may be reasonably removed by one person. ?. OWNER further represents that access to the control panel may be readily achieved during contract maintenance visits. 3. OWNER grants to OPERATOR, its agents, employees, consultants, contractcrs and subcontractors, entry to the Site, from time to time, for the purpose of performing the services as described in the Agreement. If ' occupant is not the owner of the site, occupant warrants and represents that he has permission of the OWNER to grant OPERATOR this right of entry. OPERATOR agrees to take reasonable precautions to minimize damage to the site from use of equipment required to perform the services ' and the cost of any correction, repair or replacement resulting from OPERATOR's entry onto the Site shall be borne by OWNER. In the ' event that OPERATOR shall require access to property that is not owned by OWNER for purposed of making surveys or other investigation. OWNER shall mak e all necessary arrangements for OPERATOR to gain access to such property. If OWNER cannot make such arrangements and OPERATOR cannot perform its services as set forth in the Agreement because of such failure to gain access, OPERATOR's services shall be terminated and OWNER shall pay for all costs incurred by OPERATOR up to the date of termination, and for all services of OPERATOR's subcontractors performed after termination which OPERATOR could not reasonably terminate prior to termination notice to OWNER. VII: SEASONAL USE 1 This service contract assumes permanent occupancy of the dwelling or facili hes Specified in this Agreement. OWNER agrees to notify OPERATOR should occupancy become seasonal (i.e. unoccupied for a period in excess of S to 10 weeks). Vllf: PROVISION TO TEST DATA The monitoring protocol in the permit for the installation provides data which contributes to the proper operation and maintenance of the treatment system. ' OWNER agrees to provide all test data required by the installation permit to OPERATOR in a timely manner. IX: NOTICE OF FAILURE ' OWNER grants OPERATOR the authority to independently notify the appropriate authority of any event of electrical or mechanical failure within the treatment system or of any event which may adversely effect the performance of the treatment system. X: NOTICE TO TRANSFER In the event the property is sold or otherwise transferred the OWNER agrees to ' notify OPERATOR by promptly completing the transfer document attached to this contract. OPERATOR agrees to provide continuity of service for the party to whom this contract is transferred under the same terms and conditions herein stated. a XI: CERTIFICATION OPERATOR agrees to provide upon request certification that it has appropriately pp opriately maintained the Bioclere treatment system in the manner provided for in this contract. XII: INSURANCE AND INDEMNITY OPERATOR shall not be responsible for any loss, damage or liability arising ' from OWNER's willful or negligent acts, errors and omissions or_ for those by OWNER's staff, consultants, contractors and agents or for any person for whose' conduct OPERATOR is not legally responsible. OWNER shall indemnify OPERATOR, its officers, directors, agents, and employees form all claims, demands and causes of action, including expense of defense for personal injury and loss or damage to property owned by third parties arising out of or in any Hamner connected with or related to the performance of services and caused by the negligence or willful misconduct of OWNER. Such indem nification shall include, but not be limited to, the cost of defense arising out of or in any way connected with the presence, discharge, release, or escape of contaminants of any kind excepting only such liability as may arise out of OPERATOR's sole ne`li`ence in the performance of services. 1 XIII: SERVER ABILITY: ASSIGNMENT If any provision of this Agreement is held invalid or unenforceable, all remain i provisions shall cont inue in fu ll force and effect. OWNER shall not assign any aspect of the Agreement except upon the prior written consent of OPERATOR. Upon conveyance and/or transfer of the tittle to this property, the buyer or ' successor in title agrees to abide by the terms and conditions of this agreem ent'. In i the event of a conveyance, a new agreement shall be prepared for and signed by the successor in title. J.. XIV: R i FORCE yIAJEURE '. OPERATOR shall have no liability for any failure to perform or for any delay in performance due to circumstances beyond its reasonable control. XV: TER,VIINATION This Agreement may be terminated by either of the parties by providing written notification to the other party at least ten (10) days prior to the date of termination. The local Board of Health shall be notified by the OWNER in writing in the event of change of ENGINEERS for this work or in the event of chan«c in the occupancy or owner of the premises. The g parties to this Agreement here p � by accept the terms and conditions of this A-ree.ment 1 By: Date: By: Date: 1 =rl:'I RCr,-'F1'1T-.L r �n� 1EG 22,9 Schedule A OPERATIONS AND MAINTENANCE TASKS SERVICE FREQUENCY Inspect wastewater treatment h rj,i y, Each vM(as equlmd) complete log book and make necessary Prooesa adjustments Inspect/dean all components of the system Each visit (as required) Routine sampling and analysis Each visit as ul Weekly sampjhV of DMR Weekly(as reclu md) Quarterly sampling of monitorirC welts Quarterfy(as required) Conduct routine preventive maintenance Pumps/Brower lubrkmtlon/adjustment . per vendor manuals Aeration system operation and maintenance tack visit Dfsinfec ion equipment checks each visit v Arrange for slu dge hauMg and d4osal as requtred Prepare and submit compliance reports MontNy ' compllance evaluation Inspection Annually Engineering/operations Inspoction/ruport Annually Meetings with DEP As ub-ed Repair and replacement of equipment As require Collection system inspection Annually Management oversight Continuous Insped dosing beds,check piemmetars monthly monbdnq welts,valve chambers for damage, ' vandalism Annuai cleaning/inspectlon of erift system Am,u py Vanasse Hangen Brustlin,Inc. ■ Appendix D Zenon System See Design Catalog of Parts and Equipment from Zenon (Separate Report) ' M\LD\05I 620m MemosMastemter Treatment\Cotuit O&M 2_VHBformat Appendix D: Zenon System B Vanasse Hangen Brustlin,Inc. 1 i ■ Appendix E: Control Diagrams and Pump Stations i i 1 i 1 i 1 i 1 1 1 . M\LD\051620ocs\Memos\Wastewater ' Treatment\Cotua O&M 2_VHBfonnat Appendix E: Control Diagrams and Pump Stations v f Town of Barnstable BOARD OF HEALTH 8 t John T.Norman Board OI Health Donald A.Gaudagnoli,M.D. i BAD NSTAULL F.P.(Thomas)Lee,. MASS Daniel Luczkow,M.D. Alt. q7 1639. . 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, 3056, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 814 Issue Date: 01/01/2022 DBA: SUPER STOP & SHOP/ HISSHO SUSHI OWNER: LWIN FAMILY CO. LLC Location of Establishment: 3900 FALMOUTH ROAD MARSTONS MILLS„ MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE- ICE CREAM: C�A 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: e� For Office Usb-OnLy, Initials: _ `"�'°` Town of Barnstable ' I DAte Paid r S $„HAS IrRspectional Services 9�°rEDMA�A'0� <( ak-:p Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE A4' a'4'X)Li NEW OWNERSHIP RENEWAL I' NAME OF FOOD ESTABLISHMENT: "i`JSh® 6t14 <�5TO p, 6hop. ®®CO(D ADDRESS OF FOOD ESTABLISHMENT: 311po roJxrnOL)-rh � McuvMo Mbl 1J —h A 02.Cou13 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 44CPPI 5 e�Q C/t�4 lL ChctJOVe- -kC' E-MAIL ADDRESS: (tornP671cp— e �;M6& A L• G8ro TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (moo )a Zb _ 2 2-00 TOTAL NUMBER OF BATHROOMS: WELL WATER:YES_NO )4 ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_� SEASONAL: _._- DATES OF OPERATION:_/ /_ TO. NUMBER OF SEATS:INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. 'OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? ---IS-AN-AIR-CURTAIN-PROVIB 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 508-8624644 Q\Application Forms\FOODAPP 2020.doc l OWNER INFORMATION: �^�— FULL NAME OF APPLICANT b Ee r1 qa CLX.V-d k SOLE OWNER: YES EO OWNER PHONE# ADDRESS_��p�� 5�ee.+� (/Ut1L�C. Chd�e — I�G 2.•aZ��J CORPORATE OWNER: L-W t lo ro ynolq C{) •Lv- CORPORATE ADDRESS: .SJA'oy- 0,J �2 ( hcxa- r t` PERSON Vi CHARGE OF DAILY OPERATIONS: 91-10 List(2)Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div.will NOT use past years' records.You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1,ntriot W-jo Q�! l 2 /2o22, 1. 2. .a0K 09 lob /V--3 _ 44 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:/h�w��°.to��nofbarnst�ble.us/healthdivisiott/al�plic.ations.lsp. 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 TIC COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. QAApplication FonnsTOODAPP REV3-2019.doc :f' �t Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. f Paul J.Canniff,D.M.D. MMI F.P. Thomas Lee Alternate 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: 814 Issue Date: 01/01/2021 DBA: SUPER STOP & SHOP/ HISSHO SUSHI OWNER: LWIN FAMILY CO. LLC Location of Establishment: 3900 FALMOUTH ROAD MARSTONS MILLS„ MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r For 0 CULL— oFt�r Date Paid Initials:$ �SU�1� Town of Barnstable is � Amt Pd ' &MMSTABLE, c Inspectional Services Mass. $ Check# "I)�9dr��. �-17 i22F- �' 'b'� • Public Health Division ArED Mpr 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 J2-04-ZU�J NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: N1566 6 Al�e, ETp p i S�Op COo O ADDRESS OF FOOD ESTABLISHMENT: 3Oloo r�Jy000tk, { d �, A�� p2&`d8 j MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ��q�q '� Ck&k Td I CW0re ► 1'46 Z8113 E-MAILADDRESS: anAl,cly10E �e 1wr�lU�rJ11�J 1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: C _ SEASONAL: DATES OF OPERATION: -::�/0 W TO NUMBER OF SEATS: INSIDE: 16 OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT ?)Re Y& Ca R-7010 4q e5 SOLE OWNER: YES 1�T0 )�� �,OWNER PHONE# 4Gq Z6 ZZ�i� ADDRESS )ACIuq 5Jee(e CUtk Rd, ChOdoTTe -NC' 082�3 CORPORATE OWNER: L k11 o w-ct-a,,,'kj C4o. _U C' CORPORATE ADDRESS: ✓ACIL(� 5��2 G.� 1M , C OS , 2-0Z-�3 PERSON IN CHARGE OF DAILY OPERATIONS: ►mot 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. havkd 100 Cq /z$ i 2`nz 1. hai� �W 9 i p-5 i gq 2. 00 uk 61116 /,23 61L J/ dyi 70-2-0 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 oi)eninc!! 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/apl)lications.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 I st. Q\Application FormsTOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BA►Wrg ABUL 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, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 814 Issue Date: 12/10/2019 DBA: SUPER STOP & SHOP/ HISSHO SUSHI OWNER: LWIN FAMILY CO. LLC Location of Establishment: 3900 FALMOUTH ROAD MARSTONS MILLS, MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: C,�A FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �FIME 1p� Initials: Town of Barnstable Date Paid Amt Pd$ 9BA MASS.L£, Inspectional Services NIA38. 116jq 2 A�EOnhPyA Public Health Division cheek# 0 Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 I APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT n DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: &SNn�e SC�XJ�-Gow 01JO e ADDRESS OF FOOD ESTABLISHMENT: a)1Oc) Rxke b Vd', `(`(1GJt2aun& YY�y.S �a1Q t MAILING ADDRESS(IF DIFFERENT FROM ABOVE): N %Oki Oem—Yid•. E-MAIL ADDRESS: CC`)(1TY�1�Q)(1(` Y1i, S.��L• CAr� `._.'� -) i? TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (A �- 2oo TOTAL NUMBER OF BATHROOMS: i WELL WATER:YES N�... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:../ / TO i t NUMBER OF SEATS: INSIDE: Q OUTSIDE: 0 TOTAL: O c SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. c E 2 ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING t REQUIREMENTS. 1 IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? �C IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? I TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE 4 RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD j 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:1Application Fom1s1F00DAPPRLV2018.doc s r 1 PLEASE CALL 508-862-4644 OWNER INFORMATION: p,1 ,—ZW" 0�/1 FULL NAME OF APPLICANT � �CUI—1Wt1 1, SOLE OWNER: +YES/� �nn��OWNER PHONE ADDRESS \\C� ` �uk �C. �•, �st U-c\O, ne, CORPORATE OWNER: QD•UL�-FEDERAL ID NO. : i CORPORATE ADDRESS: l �,Q �JC \Rlj1 ,Sa(�O►�t2\t .Y1C�5��3 g PERSON IN CHARGE OF DAILY OPERATIONS: U 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 Na� %. halm K � -� _ b 1. nrana,Shun kftm K&,K, Ot 2 2. i SIGNATYWWF 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. r 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:/hvww.townofbarnstable,us/liealtlidivision/applications.as1). 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.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN y THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC l st. 1A lication 1�orms1F00DAPPREV2018.dw Q� PP Party Platters - - No matter the occasion,Hissho Sushi can make > ' Living Color Roll /'*SSyour nextparty a success with our delicious and beautiful sushi party platters. � ' '• Ask our sushi chef for details.Please dive chef rig hours odvance notice. SUSHI� �' ,w�}>t _ - ' Appetizer Platter* 220-240 cal. j ; L,•, Spring Roils.Sd od.Edomome S Tura Poke Hissho Crunchy Lover* 200 cal. Crunchy Shnnp Roll.Sru o:.na Party,\Nasabi Crunch,Krispy Krab e Tempura Shrimp Roil Honolulu Queen 110-120 cal. u, F MENU Ca:ifarn�a Rol?.Veggie Roll,Phil+ade!phia Rai!Lz "` Hissho Hclthee Roil �� "' Kyoto Majesty* 200-230 cal. ' Co5forria Roll,Sunset Roil,VJasab Crunch,Sriracho Party, '• ° - '�- K spy K.I ob.Rising Sun Roll S Mgi_, Osaka Monarchy* 160-200 cal. f Caiifornio Roll,Nippon Favorite.Hissho Helthee Roil, Dynan,to Rol!.Outer So,ks Roll 9 Nigiri Sazanka" 200-230 cal. Snrocho Party Philadelphia Roll to Nioiri " •- '�• 1 rS-s is .. ssw"'444III��� Yokohama Dynasty* 170-200 cal. TNT Tempura Shrimp Roll.Living Color Roll Outer banks Poll e Nigin l r.' P" '' c •r, ,rg� ', !t Thene items c.^.rta'n or may r-ontoin raw or unoercac..ed ingredients.Consuming raw - 1- 0,P9 ar undercoo.ed meo_s,pouirry.seafood,shell-":sh,or eggs may increase your risk of '- s fcodbarne illness. rt `; i >r Not a I tens available at all locations See store for details. Nutritional Values Include A Serving Size of Ginger Vdasebi and Say Sauce. °u 2,000 Colones A Day Is Used For General Nutrition Advice,eat Caic,ie.Needs Vary. , • y Aadt:onol Nutraonal Intlormation Avowable Upon Request Of ", ^rm ' ❑ t f � .sue,.. "i, � Lx�,'� � ';• `r� � �� LJ .x „� f ' Os aka saka Monarchy '" ., "'" I as s cp .a J 4. Coosa .r y,- Q C> `�� Starters Maki Sushi Specialty Items Baby Octopus Salad 170 cal Blazing California Roll 400 cal. Caterpillar Roll 350 cal. Spicy Imitation Crab,Avocado 8 Cucumber Grilled Eel 6 Imitation Crab Roll lopped with Avocado Slices 8 Edamame 280 cal. California Roll 210-230 cal. Japanese BBO Sauce Gyozo•D, , ::: 230-310 cal. Imitation crab.Avocado 6 Cucumber Crunchy Shrimp Roll 350 cal. C.rcken/Vegetobe/Pork Shrimp Solad 6 Cucumber Topped with Tempura Flakes, Dynamite Roll* 300-380 Cal. Jaoarese BBO Sauce&Spicy Mayo Inari•FnE-d Tofu 270 Cal. Spicy(Cooked Shrimp/luno/SolmorJYellov taii), Imitation Crab 6 Avocado Dazzling Dragon Roil* 510 Cal. Mini Nagano*•Nic i. 130-230 Cal Blazing California Peal Topped with Tuna S'aces.Temc:ra Eel/Shrimpi luno/Salmon/Yellowtail Eel Roll 200 Cal. Crunch.Jolopeno,Spicy&Ulosai;(Mayo Grilled Eel 6 Cucumber Topped with Japanese BBO Ocean Spring Roll* 390-430 cal. Sauce Krispy Krob 410 cal Tuna and/or Salmon,Lettuce,Cucumber,Carrot 6 Spicy Irnitation Crab.Cucumber 8.Avocado Topped with Avocado Hissho Helthee Roil 250-370 Cal. Sesame Seeds.Spicy Mayo.•Joponese BBO Sauce 8 Fried Carrot,Cucumber,Avocado&/or Irritation Crab Onions Seaweed Salad 120 cal. Nippon Favorite* 270-360 cal. Living Color Roll` 240-360 cal. Spicy Inari* 410-450 Cal Grilled Eel,Cooked Shrimp.Tuna or Salmon California Roll Topped with Fish Slices,Gr filed Eel&/or Cooked Fred Tofu with Spicy Shrimp/Tuno!Sa!mon Snrimp Philadelphia Roll 320 cal. I Spring Roll 300-530 Cal. Imitation Crab,Avocado S Cream Cheese Mango Tango 290 cal. Lettuce.Cucumber.Carrot.Avocado,Conked Shrimp 6 Mango,I r itaticn Crab,Avocado 8 Curuniber Topped with Imitation Crab Snow Crab Roll 230 cal Shrimp.Wosabi Mayo 6 Diced Mango Real Crab.Avocado 6 Cucumber Squid Salad 160 cal. Outer Banks Roll* 450-470 cal. Spicy Roll* 230-320 cal. Tuna.Salmon,Yellowtail S Avococic,Toppeo with Sirocho Chef Tuna Poke* 290 Cal. Spicy(Cooked Shrimp/Tina/Salmon/Ye!!owtoil) Sauce 8 Spicy May Seaweed Salad,Spicy Tune Cubes.Sesame Oil Topped 6 Cucumber mt"h Scallions * Rising Sun Rol* 470-650 cal. Sushicado 230-300 cal. Tempura Shrimp Po!I Topped With.Spicy(Shnmp/Tuna/ (Cooked Shrimp/Tune/Soirmon)6 Avocado Salmon/"Yel!cwtaill 6 Jalapeno Combos Veggie Roll 200-220 cal. Salmon Lover* 590 cal. Avocado.Carrot 6 Cucumber Spicy Salmon:,Avocado 6 Cream Cheese Topped•with Salmon,Slices,Scallions 6 Mayo Hissho Spicy Combo* 580-650 cal. Sri-acho Party,Southern Charm Roil 6 TNT �` Southern Charm Roll* 390-440 cal. Spicy(Cooked rrob).Cucumber mber 6 Maui Bento* 480-900 cal Avo o c Topo d with Sesame See is Spicy Moyd Japanese ('hef's Choice Susr'Sampler I ouch Box mn California Roll �h Seaweed g` _Br Sauce 6 F nerd Onions Salad 6 Nigri(Shrimp.Tuna,Salmo^or Ye lowtoil) Sriracha Party* 380 Cal. Nagano Special* 370-730 cal. . t Sp`cy'Funo.Im tat'on Carob 6 Cucumber Topped with Sriracha r - Pea=.Japanese BBC)Sauce 6 Spicy Mayo N pint(Shrimp.Tuna.Salmon.or YailowtaiD * "v `-' -•°- Sunset Roll' 420 cal. Sashimi 50-410 cal. ' a �."� In-,P:atior,Crag Cucumber 6 Avocado Topped-Sliced Frsn i ..,,q �.+„ Spicy with Diced Salmon 6 Tuna.Scallions Mascot.Spicy MCNa Special Cooked Combo 520-620 cal. Sesame O t 5 Hissha Chili Oil Kr spy Krob,Crunchy Shrimp Roll.Tempuro Shrimp Rol!or ,},wy.,:p,. '�[_. �' Tempura Shrimp Roll* 490-500 cal. Wosabi Crunch r y" �• y" . Tempura Sh,iinp,Avocado Cucumber or Caplin Roe Sushi Lover Combo* 480-690 cal. '*Sunset Roll.Living Color fJ r Roll igir TNT* 390-470 cal. i `' - ;, .,iy4 I ,, r • Dynamite Roll Topped with Spicy(Shrimp/Tuna/So rnon/ q, Yellowtail) ..,t.;: dF f 7k Tnese illems contain or•nay c.onm;n raw or unoerccoked Ingredients Consuming row F t xy or undercooked meats poultry,seafood,shellfish.or eggs may increase your risk of Wasabi Crunch 290 Cal. Wascbi Shrimp.Avocado 8 Cucumber Topped with\Nosabi fo odborne illness p pe Peas S Wosabi Mayo No'all items avimable at al'local Cris. See store for details. ,., _ ,,.,.•� 'k- t') Nut aionoi Values Include A Serving Sze of Ginger Wosoo,and Sciy Su..,ce. _ �'• � ~a r 2000 Calories A Day Is Used For General N,,:'Yon Advice But Calorie Needs Vcry. +� y-✓ ., yr. -`. + '� " Additions!Nutritional Information Available OF�r Request y� TOWN OF BARNSTABLE - �J HEOFFICE PECTOR's Establishment Name: 1t '���l�p Ise,J� 1 Date: Page:. of P . IRS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. - 200 MAIN STREET VVV 3:30-4:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS, MA 02601 O MON.-FRI. NO Reference R-Red Item PLEASE PRINT CLEARLY FO ESTABLISHMENT INSP T" N REPORT 508-8624644 NameRM Date voe of Tyoe of Inspection O e Vs Address oo ervic Re-inspection Previous Inspection Telephone Residential Kitchen fe Mobile tio Owner HACCP Y/N Temporary ness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP �✓ n /) Other r Inspector t: - Each violation checked requires an explanation-on the narrati a 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 Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ n FOOD.PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 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 TIMEfrEMPERATURE 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) w ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP / ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY iVv ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories r Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations / Critical(C)violations marked must be corrected immediately. (blue 8 red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating W1 within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ® Embargo ❑ Emergency Closure ❑Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health.. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils FC-4 590.005 B=One critical violation and less than 4nOn-critical violations 9 ( )( ) cited in this report.may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 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 C=2 critical violations and less than non-critical. . f 1 critical refrigeration. critical water,sewage bads-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 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address anon-critical violations. If within 10 days of receipt of this order. violation,4 to anon-crittical violations 29.Special Requirements (590.009) 30.Other DATE OF RE-INSPECTION: Inspe r' mature ® /►Q 31.Dumpster screened from public view I/ Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N j2aM ,95 #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 WD ) (� Dumpster Screen Y N l iW 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 EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) * 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 7-102.11 Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 3-302:11(A) Food Protection* 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 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)Resumed Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and * 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a 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 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) Comrninuted Fish,Meats&Game Pathogens* eB cn�e innooi 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°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D).in_cater- Chemical 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* 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 Requirements.practices ould be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C), Commercially Processed RTE Food-140°F* Blue Items 23-30) 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 205 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 s Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402. Records,Creation and Retention Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical Rem in the federal 1999 Food Code or 105 CMR 590.000. BOARD OF HEALTH Town of Barnstable j3 f Cj \O�t O Health John T. n Board � lth Donald A.A.Gau Gaudagnoli,M.U. ,[tnR �rn�st .� !; Paul J.Canniff,D.M.D. ``•9\ '"1,S F.P. Thomas Lee Alternate � 639•Z%b 200 Main Street, Hyannis, MA 02601 �E'o a hi 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: 814 Issue Date: 11/01/2019 DBA: SUPER STOP & SHOP/ HISSHO SUSHI OWNER: LWIN FAMILY CO. LLC Location of Establishment: 3900 FALMOUTH ROAD MARSTONS MILLS, MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE -FOOD: MOBILE- ICE CREAM: G. 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: Town of Barnstable BOARD OF HEALTH John T. Norman Board Of Health Donald A.Gaudagnoli, M.D. RNSTABLE Paul J.Canniff,D.M.D. � \ � 79.� 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate t�P�gb 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: 814 Issue Date: 11/01/2019 DBA: SUPER STOP & SHOP/ HISSHO SUSHI OWNER: LWIN FAMILY CO. LLC Location of Establishment: 3900 FALMOUTH ROAD MARSTONS MILLS, MA 02648 Type of Business Permit: SUPERMARKET Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE- ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: cc�� SUJ a JJ � Bellaire, Dianna 2A or) From: Miorandi, Donna Sent: Tuesday, June 23, 2020 11:08 AM To:, Bellaire, Dianna Suliiect: RE: Snack shack Thanks and Hissho Sushi is also all set. Z Anna-Z. 'Itiorancri, 41. Town of Barnstable Health Inspector Public Health Division 200 Main Street, Hyannis, MA 02601 The information contained in this electronic transmission ("e-mail"),including any attachment(the "Information"), may be confidential or otherwise exempt from disclosure. It is for the addressee only.This Information may be privileged and confidential work-product or a privileged and confidential communication.The Information may also be deliberative and pre-decisional in nature.As such, it is for internal use only.The Information may not be disclosed without the prior written consent of the Director of Public Health and/or the Town Attorney's Office of the Town of Barnstable. If you have received this e-mail by mistake, please notify the sender and delete it from your system. Please do not copy or forward it.Thank you for your cooperation. From: Bellaire, Dianna Sent: Tuesday, June 23, 2020 10:31 AM To: Miorandi, Donna Subject: RE: Snack shack Mailed their permit today. 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 'T'he infortnation.-onta.ined.in this electronic tratnsmission ("e-marl"),.including a.ny attachment(the"Information"),may be confidential or otherwise exempt from disclosure.It is for the addressee only.This Information may be privileged and confidential work-product or a privileged and confidential communication.The Information may also be deliberative and pre-decisional in nature. As such,it.is for internal use.only.The Information may not be disclosed without the prior written consent of the Director of Public f lealth and/or the Town.Attorneys Office of the Town of Barnstable. If you have received this e-mail by mistake,please notify the sender and delete it from your system.Please do not copy or forward it.Thank you for your cooperation. 1 1/26/2018 Thunder Group Inc.-30 CUP RICE COOKER/WARMER(SEJ50000) THUNDER VV �ffi Toll Frees 1-866-TARi•iONG F � �� wac+Ji�• Your Value added One Strap Supplier Honte About Us •+ i�Q }rder Status Contact Us • WORKTABLES Home / Products / GAS @ ELECTRIC UNITS GAS & ELECTRIC UNITS p TANKLESS WATER HEATER 30 CUP RICE COOKER/WARMER • ASIAN COOKWARE Item#: SEJ50000 M ASIAN TABLEWARE Inner Box: 1 Q BAKEWARE&SUPPLIES r -� "" —r 7, Master Box: 1 SI BAR SUPPLIES - ' - Oil -- - CATERING&BUFFETWARE N.W(Ibs): 15G.W(Ibs): 20 FOOD PREPARATION Master Pack Cuft: 2.06 GAS&ELECTRIC UNITS View price or place order. Click here register or sign in. JANITORIAL f 12 KITCHEN UTENSILS MELAMINE,ASIAN " ® MELAMINE,WESTERN RAMEKINS [b.EHI.ARGE IMAGE(Image may vary) LADLES AND SPOONS PROFESSIONAL U` a COOKWARE ' SHELVING Thunder Group 30 cup/60 bowls rice cooker/warmer.This rice cooker cooks 30 cups of rice with ease and also keeps the rice warm SIGNAGE automatically after cooking.With two functions In one,this is the ideal rice cooker for all settings. Package in color box. NSF and UL listed. TABLE TOP SERVICES This NSF safe and UL approved appliance cooks and warms 30 cups or 60 bowls of rice in 30 minutesl It*s one of the leading most i FLATWARE reliable rice cookers in the food service industry.Cook rice hassle-free and automatically switch to warm.Unit is ideal for buffets, restaurants,catering,parties,weddings and banquets.It comes with a free rice spatula. SECURITY CAGE • Serve up to 30 cups/60 bowls of rice • Cooks 30 cups of rice in 30 minutes • Cooks and also keeps rice warm • Du, ble white powder coated finish body • Bright polished finished stainless steel top cover • Heavy grade aluminum inner cook pat • Easy to open stainless steel lid with durable handles and sturdy legs • Includes free rice spatula and 5 cups measuring cup • Easy to clean • Energy efficient • NSF approved,UL approved • Easy one touch lever operation that automatically switch from cook mode to warm mode • Ideal for buffet,brunch,catering,party,wedding banquet and kitchen area • Dimensions:17"D x 14°H(include top cover and side handles) • Model:SEJ50000 • Voltage:11OV-120V • Wattage:1780W 60 Hz AC • Ideal for commercial use Home Products • Job Opportunity • Terms and Conditions • Privacy Policy TradeShows Copyright m 2018 Thunder Group Inc.All rights reserved. SA ititCfFU?IQk RIStNDISlTlt4 /�`;i I[ y http://www.thundergroup.comlapp/stx.productdetall.asp?did=2364 1/1 Waterproof Pen Style Model #: DPP400W �s This waterproof digital thermometer is NSF certified and has automatic shut-off. Designed with anti-microbial additive to avoid bacteria growth and reduced stainless steel tip for a quick response time. Product Specifications Warranty Lifetime F/C Switchable Yes Auto Off After 10 minutes of non use Certifications NSF, CE, RoHS,WEEE Temperature Range -40'to 392°F (40° to 200°C) Temperature Accuracy f2°F (1°C) from 140 to 2120F(-10°to 100°C)f3°F (1.5°C) all other ranges Ambient Temperature 32' to 120°F(0'to 49°C) Range Resolution 0.1°F from-40 - 199°F, 1 OF from 200 - 392°F, 0.1°C throughout the entire range LCD Height .25" Waterproof Rating IPX7 Waterproof Rated Housing Material ABS plastic w/antimicrobial additive Sensor Type Thermistor Response Time Reducted tip for<6 second response time Shaft Length 2.75" (69.9mm), .75" (19mm)tip Shaft Diameter 0.046" (1.19 mm) at Sensor Battery Type 1.5v#LR44 battery Battery Life 500 hrs Weight 0.9 oz Dimensions 3/4" x 5/8" x 6.0" (19 mm x 15.8 mm x 152.4 mm) (w/sheath) USER GUIDE EXTECH INSTRUMENTS ExSti kTM pH Water roof Meters p Models PH100 and PH110 Patent Pending EXTECH* INSr.-Ews ppm pH mV;_.� el.8.82 (DO 0 BAT HOLD REcm7 .®.®F pI1 Mehl MODE HOLD CAL RECALL ON OFF PH100 ExStiK CE Introduction Thank you for selecting the Extech Model PH100 and/or the model PH110 (refillable) meter. This instrument is designed for high accuracy pH testing. This device is shipped fully tested and calibrated and, with proper use, will provide years of reliable service. Please visit our website (www.extech.com) to check for the latest version of this User Guide, Product Updates, Product Registration, and Customer Support. i I ' i 2 PH 100/PH 110-en-GB_v3.1 3/15 ExStikr' Description Front Panel Controls 1. Battery compartment cap E17ECH 2. LCD Display 3. MODE/ HOLD button ®�e:B; 2 4. CAL/ RECALL button PH- 5. ON/OFF button 4 6. Electrode collar 7. Electrode (refillable) 5 ExShk' (Electrode cap is not shown) 6 7 Display 1. Bargraph reading ```��1 4f�� 2. Measurement reading �N� 7.0 �i� 3. BAT (low battery) and 5 2.0 pH 12 HOLD (data hold) indicators 6 ® v 4. Temperature display 5. Bargraph scale designations 7k ' ' '.0 ' 6. Units of measure O 10 BAT HOLD 3 7. Calibration indicators 8. RENEW and CAL indicators $ I� ' 'RENEW I0 I0 4 °°F CAL �_ . . _ CAUTIONS • This device is not a toy and must not reach children's hands. It contains hazardous objects as well as small parts that the children could swallow. In case a child swallows any of them, please contact a physician immediately • Do not leave batteries and packing material lying around unattended; they can be dangerous for children if they use them as toys • In case the device is going to be unused for an extended period of time, remove the batteries to prevent them from draining • Expired or damaged batteries can cause cauterization on contact with the skin. Always, use suitable hand gloves in such cases • See that the batteries are not short-circuited. Do not throw batteries into the fire. 3 PH100/PH110-en-G13_v3.1 3/15 Overview pH Overview pH is a unit of measure (ranging from 0 to 14pH) indicating the degree of acidity or alkalinity of a solution. pH tests are the most commonly performed measurements in water analysis and reports the negative log of the hydrogen ion activity of a solution which is an indicator of acidity or alkalinity. Solutions with a pH less than 7 are considered acidic, solutions with a pH higher than 7 are known as bases, and solutions with a pH of exactly 7 are neutral. The pH scale is logarithmic so, for example, if sample A is 1 pH less than Sample B, this means that Sample A is 10 times more acidic then Sample B. A difference of 1 pH represents a ten-fold difference in acidity. Getting Started • For new meters, remove the battery cap and then remove the battery insulating strip. • Remove the cap from the bottom of the ExStikT°"to expose the electrode glass surface and reference junction • Before first use or after extended storage, soak the electrode (with its cap removed) in a pH 4 solution for about 10 minutes • White KCL crystals may be present in the cap. These crystals will dissolve in the soak or they can be simply rinsed with tap water • Always calibrate close to the expected measurement value • A sponge is located in the electrode protective cap. Keep this sponge soaked with a pH 4 solution to preserve Electrode life during storage Replacing Electrodes The ExStikTm is shipped with an electrode attached. Electrode life is limited and is dependent on (among other factors)frequency of use and care. If the electrode needs to be replaced, follow these steps for removing and connecting electrodes. Note that the PH110 has a refillable electrode. 1. To remove an electrode, unscrew and completely remove the electrode retaining collar. 2. Gently rock the electrode from side to side, pulling it away from the meter, until it disconnects. 3. To attach an electrode, carefully plug the electrode into the meter socket(note that the electrode connector is keyed, ensuring proper connection). 4. Secure the electrode in place by tightly turning the collar in place. (a rubber gasket seals the electrode with the meter). Automatic Electrode Recognition When the ExStikTm is turned on, it recognizes the type of electrode that is connected and displays the appropriate unit of measure. Attach electrode before turning the ExStikTm on. Powering the ExStikTM If the batteries are weak, the `BAT' indicator appears on the LCD. Press the ON/OFF key to turn the ExStikTM on or off. The auto power off feature shuts the ExStikTM off automatically after 10 minutes of inactivity to preserve battery life. 4 PH 100/PH 110-en-GB_v3.1 3/15 Operation Overview When the electrode is placed in a solution, the main display and bargraph indicate the pH reading while the lower display reads temperature (readings flash until they have stabilized). The bargraph is 'center zero', i.e. at pH 7 there is no display. As the pH rises, the bar moves from the center to the right. If the pH drops, the bar moves from the center to the left. pH Calibration (1, 2, or 3 points) A two point calibration with a buffer of 7 plus 4 or 10 (whichever is nearest to the expected sample value) is always recommended. A one point calibration (choose the value closest to the expected sample value) is also valid. For best accuracy, always calibrate at the sample temperature. 1. Place the electrode into a buffer solution (4, 7, or 10) and momentarily press the CAL key. pH 7 should be calibrated first, then 4 and/or 10 pH. 2. The ExStikTm automatically recognizes the solution and calibrates itself to that value. Note: If the solution is more than 1 pH off from the 4, 7, or 10pH standard, the ExStikTM will assume an error and abort the calibration. CAL and END will be displayed. 3. During calibration, the pH reading flashes on the main display. 4. When calibration is complete, the ExStikTm automatically displays `END' and returns to normal operation mode. 5. The appropriate circled indicator®,OO , or 9 will appear on the LCD when a calibration has been completed. The calibration data is stored until a new calibration is performed. 6. For a two or three point calibration, repeat steps 1-4. Note: Always turn the meter off and then on before calibrating to allow sufficient time to complete the calibrations during one power cycle. If the meter auto powers off during calibration the calibrations remain valid, but new calibrations will turn the circled indicators off. Note: The Automatic Temperature Compensation (ATC)circuit is not active during calibration. To ensure a more accurate calibration, make sure that the calibration buffers are at 250C (770F). RESET If the meter will not calibrate or displays a-1, reset the meter and attempt to re-calibrate. 1. Turn off the meter. 2. Remove the battery cartridge from the top of the meter. 3. Press the On/Off button for 10 seconds to bleed off all charges within the meter. 4. Re-insert the batteries and power on the meter. 5. Attempt to re-calibrate the meter. Changing the Displayed Temperature Units Press and hold the CAL button for approx. 3 seconds. The°C or OF icon will change first and the numerical temperature value will change after the button is released. If the Calibration mode is accidentally accessed 'CAL' appears on the LCD. Simply turn the ExStikT"'off and start again. Data Hold Momentarily press the MODE button to freeze the current reading. The HOLD display icon will appear along with the held reading. The held reading will also be stored in memory. Momentarily press the MODE key to return to normal operation. 5 PH 100/PH 110-en-GB_v3.1 3/15 15-Storing Readings into Memory 1. Momentarily press the MODE button to store a reading. The LCD will briefly display the memory location pv`'��•,,o,,,,''•O. number and then the value stored (Data Hold will `° P" " activate). 10.0q 2. Momentarily press MODE again to return to normal pp® „o� operation. I $,5•F 3. Repeat step 1 to store the next reading and so on. 4. After 15 readings are stored the ExStikTM will return to memory location 1 and start overwriting existing data with newly stored data. Recalling Stored Readings Note: Check that the HOLD symbol is not displayed. If it is, exit the HOLD function by momentarily pressing the MODE button. 1. Momentarily press the CAL button and then press the MODE button immediately after CAL is displayed; the storage location number(1 through 15)will flash. If the CAL mode is accidentally accessed (display flashing), press the CAL button again to exit. 2. The last reading stored will be displayed first. To advance through the stored readings, momentarily press the MODE button. The location number is displayed first, followed by the reading stored in that location. 3. To exit the recall mode, momentarily press the CAL button and the ExStikTM will return to normal operation. CAL Reminder Display When the ExStikTM is turned on in the pH mode for the 15th time without recalibration, the `CAL' icon appears on the LCD indicating that the ExStikTM may require calibration. Some applications may require recalibration of the electrode more frequently than others. The CAL display is simply a reminder and will turn off when the pH electrode is recalibrated. RENEW Display A flashing 'RENEW warning indicates that the probe may be nearing the end of its useful life. If cleaning or recalibration does not cause the RENEW icon to disappear, replace the electrode. The RENEW display appears when the output of the pH electrode fails a diagnostic test. Considerations • If the unit appears to be locked (display frozen) it is possible that the Data Hold mode has been inadvertently accessed by pressing the MODE button. Simply press the MODE button again or turn the meter off and restart if the display appears frozen. • If the meter does latch up and no button presses revive it, remove the batteries, push the ON button for 10 seconds and then reinsert the batteries. • Note that if the batteries are removed, any stored readings will be discarded. Also, the user calibration data for pH will be cleared. New user pH calibration data is required. Factory calibration data for all models will be retained, however. I 6 PH 100/PH 110-en-GB_v3.1 3/15 Battery Replacement (p (p 1. Twist off the battery compartment cap +III—III+ 2. Replace the four(4) 2032 batteries observing polarity. 3. Replace the battery compartment cap Ily Never dispose of used batteries or rechargeable batteries in household waste. As consumers, users are legally required to take used batteries to appropriate collection sites, the retail store where the batteries were purchased, or wherever ® batteries are sold. Disposal: Do not dispose of this instrument in household waste. The user is obligated to take end-of- life devices to a designated collection point for the disposal of electrical and electronic equipment. Other Battery Safety Reminders o Never dispose of batteries in a fire. Batteries may explode or leak. o Never mix battery types. Always install new batteries of the same type. pH Electrode Refilling (pH110/115 refillable electrode only) The refillable electrode does not need to be detached from the body of the ExStikTm in order to perform the refilling procedure. Refillable electrodes Refillable (PH115) have a removable reference junction (slotted) and the word pH Module REFILLABLE on the side of the electrode housing. Removing the Reference Junction The removal tool supplied with the PH113 Refill Kit is used to remove the reference junction from the sensing surface of the electrode. If the reference junction does not have slots for the 'teeth' of the removal tool to Junction removal tool lock onto, the electrode is NOT refillable. Holding the electrode upside down, unscrew Refe ence junction and remove the reference junction using the removal tool. Filling the Electrode 1. Once the reference junction cQ3 is removed, fill the cavity with the refill solution supplied in the Refill Kit. 2. Replace the reference junction using the removal/installation tool. (Spare junctions are provided if needed). Filling Solution The supplied container includes 15ml of filling solution. There is enough solution for 4 to 5 refills. Use only the supplied solution for refilling the electrode. 7 PH 100/PH 110-en-GB_0.1 3/15 Specifications Display Multifunction LCD with Bargraph Operating conditions 32 to 1220F (0 to 50°C)/< 80% RH Range and Accuracy 0.00 to 14.00/± 0.01 pH typical Temp. Compensation Automatic from 32 to 1940F (0 to 90°C) Temperature Range 23 to 1940F (-5 to 90°C) Temperature Resolution 0.10 up to 99.9 then 1°thereafter Temperature Accuracy ± 1°C/1.80F [from -5 to 500C (23 to 1220F)] ± 30C/5.40F [from 50 to 900C (122 to 1940F)] Measurement storage 15 tagged (numbered) readings Power Four(4) CR2032 button batteries Low battery indication `BAT' appears on the LCD Auto power off After 10 minutes of inactivity Dimensions 1.4x6.8x1.6"(35.6x172.7x40.6mm); 3.85oz (110g) Optional Accessories • Tripak buffers with 4, 7 & 10 pH capsules (6 each) plus two rinsing solutions (Part Number: PH103) • pH 4.01 buffer, pint, (Part Number PH4-P) • pH 7.00 buffer, pint, (Part Number PH7-P) • pH 10.00 buffer, pint, (Part Number PH10-P) • Spare pH Electrode—non-refillable (Part Number: PH105) • Spare pH Electrode- refillable (Part number PH115) • Electrode Refill solution (Part number PH113) • Spare ORP electrode(Part Number: RE305) • Spare Chlorine electrode (Part Number: CL205) • Weighted base with 5 solution cups (Part Number: EX006) Note: If the unit is to be converted for ORP or Chlorine use by attaching the proper electrode, please visit www.extech.com to download the proper User Guide Copyright © 2014-2015 FUR Systems, Inc. All rights reserved including the right of reproduction in whole or in part in any form ISO-9001 Certified www.extech.com 8 PH 100/PH 110-en-GB_v3.1 3/15 i*sh hu. MASSACHUSSETTS 20,19 SSOP/HACCP Sanitation Standard Operating Procedure/Hazard Analysis Critical Control Points (DO NOT REMOVE FROM FOOD RETAIL UNIT) Owned and Operated By Lwin Family Co. 11949 Steele Creek Road Charlotte,NC 28273 Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 2 Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 January 1, 2019 This letter certifies that all information contained in the nutrient analysis is complete and accurate. All information was determined utilizing the nutritional software, Genesis R&D. Sincerely, Brian Kiel Vice President of Operations,Lwin Family Co.LLC compliance(a),hisshosushi.com 704-926-2200 www.hisshosushi.com 11949 Steele Creek Road•Charlotte,North Carolina•28273.704.926.2200•Fax 704.926.2201 (*shoRmRhc0), January 1, 2019 The parent company, Lwin Family Co. LLC, has taken reasonable steps to ensure that the method of preparation and amount of a standard item offered for sale adhere to the factors on which the nutrient values were determined. Sincerely, Brian Kiel Vice President of Operations,Lwin Family Co. LLC compliance(&hisshosushi.coin 704-926-2200 www.hisshosushi.com 11949 Steele Creek Road•Charlotte,North Carolina•28273.704.926.2200•Fax 704.926.2201 Confidential Property of Hissho Sushi Page 1 3 Table of Contents 1. Employee Health....................................................................................................................................4 Grooming.........................................................................................................................................4 Attire................................................................................................................................................4 Hair Restrains and Jewelry...............................................................................................................4 Smoking, Eating, Drinking,and Gum-Chewing................................................................................4 Operations Hours, Breaks,and Meals.:...........................................................................................4 PersonalItems.................................................................................................................................4 TastingMethod................................................................................................................................5 Handwashing....................................................................................................................................5 Glove Use ........................5 ................................................................................................................. Illness...............................................................................................................................................6 Sneezing/Coughing..........................................................................................................................6 Cuts, Burns,and Abrasions...............:..............................................................................................7 2. Cleaning and Sanitizing...........................................................................................................................7 3. Pest Control............................................................................................................................................7 4. Flow of Food...........................................................................................................................................8 Receiving..........................................................................................................................................9 FoodStorage....................................................................................................................................9 Preparation....................................................................................................................................10 Cooling...........................................................................................................................................10 Delivery..........................................................................................................................................11 Display............................................................................................................................................11 Labeling..........................................................................................................................................11 DatingProducts..............................................................................................................................12 5. Preparation of Sushi Rice .....................................................................................................................15 6. Recipes..................................................................................................................................................25 7. Food Safety Hazards.............................................................................................................................25 8. HACCP Plan...........................................................................................................................................26 9. Thermometer Calibration.....................................................................................................................31 Dial Thermometer Calibration.......................................................................................................31 Thermo Works Digital Probe Calibration.......................................................................................31 10. pH Meter Calibration............................................................................................................................31 11. Logs.......................................................................................................................................................33 12. Laboratory Analysis of Sushi Rice.........................................................................................................38 13. Employee HACCP Training Procedure..................................................................................................39 14. Company Illness Reporting Agreement................................................................................................40 Foodborne Illness Complain Procedure...................................................................................:.....41 15. Cleaning and Disinfecting Procedure...................................................................................................43 .16. Taking Calls from the Media.................................................................................................................44 17. Parasite Destruction Letters.................................................................................................................45 Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 4 1. EMPLOYEE HEALTH GROOMING • Arrive at work clean-clean hair,teeth brushed,and bathed with deodorant used daily. • Maintain short,clean,and polish-free fingernails.Artificial nails are not permitted. • False eyelashes are not permitted. ATTIRE • Wear clean uniform with clean sleeves. • Wear socks and clean non-skid,close-toed and closed-backs work shoes that are made of leather or similar impermeable material.Shoes should be comfortable for standing and working on floors that can be slippery. HAIR RESTRAINTS AND JEWELRY • Wear the Hissho Sushi Chef hat that completely covers hair. • Keep beards and mustaches neat and trimmed.Beard restraints are required in any food production or service areas. • Jewelry is not permitted. o Only a plain wedding band is permitted. o No necklaces,bracelets,or dangling jewelry are permitted. o No earrings or piercing that can be removed are permitted. o No watches. SMOKING, EATING, DRINKING, AND GUM-CHEWING • No smoking or chewing tobacco may occur inside Hissho Sushi Locations • Eat and drink in designated break areas only. • A closed beverage container may be used in production areas provided it is stored in an area clearly reserved to store the drinking cups. This area must be labeled and completely separated from food preparation areas, surfaces and supplies. • Chewing gum or eating candy is prohibited. OPERATIONS HOURS, BREAKS AND MEALS • Fulltime chefs are assigned to be at the sushi bar from 7am to 7pm daily. • Take breaks and meals in a designated area away from production and service areas. • Wash hands before returning to work. PERSONAL ITEMS • Must be stored completely separate from food and food contact surfaces.Ideally they should be stored in lockers • If an employee must refrigerate medication while working,she/he must place it inside a covered, leak-proof container that is clearly labeled.In the refrigerator,store the container away from food product and food contact surfaces. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Paged 5 TASTING METHOD • Place a small amount of food into a separate container. • Step away from exposed food and food contact surfaces. • Use a spoon to taste the food.Remove the used spoon and container to appropriate location(i.e.,the dishroom) • Never reuse a spoon that has already been used for tasting. HANDWASHING • Wash hands(including under the fingernails)and forearms vigorously and thoroughly with soap and warm water(water temperature should beat least 100°F)for a period of 20 seconds. • Wet hands with water.Wash hands using soap from a soap dispenser. Lather for 20 seconds. • Wash between fingers thoroughly. • Rinse thoroughly under warm running water for 5-10 seconds. • Use designated sinks for handwashing purposes. Do not use food preparation, utility and dishwashing sinks for handwashing. • Dry hands with single use towels or a mechanical hot dryer. • Turn off faucets using a paper towel in order to prevent recontamination of clean hands if foot pedals are not available. • Use paper towel to open door when exiting the restroom. • Wash hands: o When entering the facility before work begins. o Immediately before preparing food or handling equipment. o As often as necessary during food preparation when contamination occurs. o In the restroom after toilet use,and when you return to your work station. o When switching between working with raw foods and working with ready-to-eat or cooked foods. o After touching face,nose,hair,or any other body part,and after sneezing or coughing. o After cleaning prep tables or any cleaning duty. o After touching door knobs or handles. o Between each task performed and before wearing disposable gloves. o After smoking,eating,or drinking. o Any other time an unsanitary task has been performed-i.e. taking out garbage, sweeping, handling cleaning chemicals,wiping tables,picking up a dropped food item,etc. • Follow FDA recommendations when using hand sanitizers.These recommendations are as follows: o Use hand sanitizers only after hands have been properly washed and dried. o Use only hand sanitizers that comply with the current food codes. o Use hand sanitizers in the manner specified by the manufacturer. GLOVE USE • Bare hand contact with ready-to-eat food is prohibited. • Prior to putting on gloves and when gloves are changed,wash hands thoroughly. • Change gloves when: o Beginning each new task. o They become soiled or torn. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 I Confidential Property of Hissho Sushi Page 6 o They are in continual use for one hour. • Cover cuts and sores on hands,including fingernails,with clean bandages.If hands are bandaged, clean gloves or finger cots(protective coverings)should be worn at all times to protect the bandage and to prevent it from falling into food. ILLNESS • The local regulatory requires the following for employee illness reporting: a. Food employees are prohibited from working when the employee has diarrhea or vomiting. b. Food employees cannot return to work until at least 24 hours after diarrhea or vomiting symptoms have completely disappeared. c. Food employees must report any of the following to the manager or person-in-charge: i. Any incident of diarrhea,vomiting,or jaundice(yellow skin or eye color),regardless of the cause of the symptoms within the last 24 hours; ii. An open,infected wound on the hands or exposed portions of arms; iii. Any of the following infections when diagnosed: • Enterohemorrhagic or shiga toxin-producing Escherichia coli; • Hepatitis A; • Norovirus; • Salmonella spp.; • Salmonella Typhi;Non-Typhoid Salmonella • Shigella; Food managers or person-in-charge must do the following: iv. Exclude (send home)an ill food employee who has, or has had in the last 24 hours, any diarrhea or vomiting; V. Restrict an employee from working with food or clean equipment and utensils if the person is infected with:E.coli 0157:H7,Salmonella,Shigella,Norovirus or Hepatitis A; vi. Keep a written record of all employee reports of diarrhea or vomiting; vii. Notify the local regulatory of any of the following: • An employee infected with any of the six (6) disease-causing organisms listed in 1.c.(iii) above; • A complaint from a customer who reports becoming ill with diarrhea or vomiting after eating or drinking at your establishment; • A complaint from a customer who tests positive for E. coli 0157:H7, Salmonella, Norovirus,Shigella,or Hepatitis A after eating at your establishment. viii. A medical release is required after diagnosis from a physician prior to returning to work. SNEEZING/COUGHING • Step away from food and food contact surfaces. ' • Cover your mouth.The preferred method to cover your mouth is to extend the arm so that the inner-fold of the elbow- area covers the lips allowing your hands not to be contaminated. • Promptly dispose of tissues used to cough/blow nose. • Wash hands before returning to work. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Paged 7 CUTS, BURNS, AND ABRASIONS • Immediately treat and bandage any cut,abrasion,or burn that has broken the skin. • Cover a lesion containing pus with a bandage. • When hands are bandaged,cover bandages with an impermeable cover such as gloves and finger cots. • Chefs with infected wounds will be excluded from the sushi bar. 2. CLEANING AND SANITIZING • Wash,rinse and sanitize food contact surfaces of sinks,tables,equipment,utensils,thermometers,carts and equipment: o After each use. o Any time you begin working with another type of fish,vegetable,or pre-cooked food o If in constant use,clean and sanitize at four-hour intervals. o Anytime there is an interruption during a task and the tools and items may have been contaminated. o Any time contamination occurs or is suspected. • Wash,rinse and sanitize food contact surfaces of sinks,tables,equipment,utensils,thermometers, carts and equipment using the following procedure: o Wash surface with soap solution. o Rinse surface with clean water. o Sanitize surface using a sanitizing solution mixed at a concentration of 100ppm for Chlorine, 200ppm for quaternary ammonium,or as specified on the manufacturer's label. o Place wet items in a manner to allow air drying. o Store clean food containers in an inverted position. o In between uses,keep towel inside the sanitizing solution. 3. PEST CONTROL • Pest control is performed by a licensed pest control operator who is hired by: o The area and all associated records are available on request from the management. OR o The sushi bar and all associated records should be appended to the back of this SSOP Manual. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Paged 8 4. FLOW of FOOD Receiving Food Storage Preparation (CCP) Cooling (CCP) Display Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 1 9 RECEIVING All foods are obtained from Hissho Sushi and/or a source approved by Hissho Sushi. Ingredients may be purchased as needed in between deliveries.. Hissho Sushi and its approved seafood suppliers provide fish,shellfish,crustaceans,eggs(roe)and surimi that come from sources operating under a HACCP plan.Letters indicating compliance with parasite destruction requirements are updated annually and are kept at the sushi bar at all times. All potentially hazardous foods are delivered at or below 417(5°C)or solidly frozen. A calibrated thermometer is used to monitor the internal and/or surface temperature of the incoming foods before acceptance.The thermometers provided by Hissho Sushi are end-point sensor thermometers. Chefs inspect all incoming products for product condition, temperature as necessary, integrity of packaging, and proper label information. Do not receive products that are damaged or show signs of temperature abuse.This is reported to your supervisor and logistics. Damaged and/or temperature abused product is not to be used. FOOD STORAGE All foods is protected from contamination and stored in a manner to reduce or prevent bacterial growth that could promote spoilage or potential food safety problems. Food storage includes items that are held at room temperature or in refrigeration or freezers.These items may require further preparation or they could be ready-to-eat as raw or previously cooked foods. The storage unit(s)are clean and orderly. • Products are contained and/or covered for protection. • Containers of sushi products or ingredients that are removed from the original (identified) packages are relabeled,marked for identification and dated. • Ready-to-eat items and items ready-for-display are segregated from products that require further handling or processing. • Products are not stacked without adequate support and means to prevent any leakage between products. • Drippage is prevented in or on packaged products due to condensation,cooler pan leaks or otherwet sources. • Products are stored above the floor(approx.6 inches)and away from walls and the ceiling. • Storage includes containers,shelves,supports,pallets or other materials that do not absorb water and can be easily cleaned. • The schedule for product rotation follows the'First-in First-out'rule(FIFO). Display counters are not storage units and cannot be used to store raw ingredients. Display counters for sushi are maintained at or below 41°F(5°C). Refrigeration unit(s)are operating to assure the food can be maintained at or below 41°F(5°C). Frozen storage unit(s)are operating to assure the frozen foods are solidlyfrozen.All unacceptable temperature abused,off- color, off-odor,off-condition,out-of-date or otherwise suspect product are discarded. Frozen products are thawed under refrigeration at or below 417 (5°C). Thawing must also be done in a manner that prevents cross-contamination with other refrigerated foods. Open vacuum packaged seafood products and removed the.product from the package. Place it in an NSF container with a drain shelf and shelf life label. If more rapid thawing is necessary, unpackaged products can be placed in clean flowing water no warmer than 70°F(21°C)only until Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 110 thawing is complete. Once the unpackaged product is thawed and before exceeding 417(5°C),the product is processed or returned to proper refrigerated storage.Thawing cannot be conducted in standing water,at room temperature or in running water warmer than 707(21°C). PREPARATION Sushi operations may share the work area and facilities with other food preparation units. If it is necessary to share work space with others, the Chef works with the person in charge to schedule operations, personnel traffic, product traffic, and cleaning to prevent potential cross-contamination of the ready-to-eat sushi products. Standard Operating Procedures for basic sanitation and food safety are used and documented daily on the Daily Sanitation/ Operation Log. Bamboo and plastic mats are lined with plastic film and rewrapped within 4 hours of continuous use and between contact with different sushi products. All mats are cleaned and sanitized daily. The prep schedule is arranged to minimize the exposure of potentially hazardous foods to temperatures outside of refrigeration.Each roll takes approximately 2 minutes to prepare. Fruits and vegetables are washed at the prep sink before cutting for use in sushi. Also, any cutting surface is cleaned to avoid cross-contamination before proceeding with further processing of sushi. Special care is taken in preparation of the sushi rice to prevent potential bacterial growth while assuring the rice can still be formed into balls and rolls. Contact with gloved hands is minimized to prevent cross-contamination of the ready-to-eat product. Heat during the cooking of rice can activate certain bacterial spores that can grow and release toxins unless the rice is preserved or refrigerated.Refrigerated rice is more difficult to form for sushi.For this reason,sushi rice should be carefully protected during handling without refrigeration. Proper acidification of cooked rice with Hissho Sushi's Sushi Seasoning helps preserve the rice for temporary handling at temperatures above 417(5°C),but the acid level, measured by pH,should be carefully monitored for each batch. The rice is acidified when it is warm to assure better mixing and penetration of the acid solution.The production time and final acid level (pH) is recorded for each batch of sushi rice. Acidified rice has an initial measurable,targeted pH of 4.1 and should be thoroughly mixed to assure the rice does not exceed an equilibrium pH of 4.1. A range of 3.8 -4.1 is acceptable.Properly acidified rice should not be considered a time/temperature control for safety food. COOLING Excessive time for the cooling of potentially hazardous foods has been consistently identified as one of the factors contributing to foodborne illness.Foods that are held at improper temperatures provide an excellent environment for the growthofdisease causing microorganisms(spore-fcrmers). Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi P age Ill For all foods: • Display units cannot be used to cool sushi or other foods • Make sure there is adequate air circulation around containers. • Do not cover until food is cooled,then cover. If your local regulators require all foods to be covered,then cover with plastic wrap and poke multiple holes to all allow the heat to escape. • Do not overload the capacity of refrigeration units/freezers. • Use a clean and calibrated thermometer to check the temperature at the center of the food. Make sure that it reaches 41°F within 4 hours. • Food not cooled to_<41°F(5°C)in 4hrs.will be thrown away • Finished sushi packages should be cooled in a cooler,freezer,or blast chiller until temperature is to<_41°F. Cooling time should not exceed 4 hours. DELIVERY Finished products that are transported to satellite(delivery only) locations require proper equipment and planning. The quantity of packages will determine the needed quantity of coolers and ice blankets. All finished products are only transported in pre- chilled coolers utilizing the "1-2" method (1 ice blanket layer-2 layers of finished product— 1 ice blanket layer until the cooler is full). A"delivery log"is completed for each delivered location. • The internal temperature of finished product must be 41°F (5°C) or less prior to loading in the cooler and unloading at the delivered location. The temperature and time are recorded in their respective columns on the delivery log when loading and unloading. • The coolers and ice blankets are stored in the walk in freezer overnight for the next day's deliveries. Ice Blanket TOP LAYER Sushipackages Sushi packages Cooler Box Ice Blanket Diagram Sushi packages Sushipackages Ice Blanket j BOTTOM LAYER DISPLAY Display involves holding the finished products in temperature control units for a specified duration and condition for public sale. Originally, preparation of sushi was for immediate consumption. Retail preparation and display introduces more prolonged holding that is controlled and monitored to assure product safety before consumption. • The display unit(s)maintain the sushi products at or below 41°F(5°C). • Packaged product is labeled and has a shelf life of one day(24hrs.)before discarding. • Packaged products are arranged and organized based on the type of display case and planogram. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 112 LABELING PRODUCTS You must correctly label every item you produce and put in the display case. Correct labeling and marking is important to show all the ingredients and any allergens that might be contained in the package.The labels for the packaged products have consumer advisory. It is also important so that customers can easily choose the product they want. • Never write on product labels packages with a marker. • Mark all of the correct ingredients on the label that are used. • Place label along the bottom of the container. DATING PRODUCTS You are required to date all the products properly. Be aware of the shelf life of products. Products are dated with a "Use By"date. On the date of expiration,discard items immediately upon arrival to the sushi bar.The specific time of preparation of an ingredient may be included on the label,as a reference for the specific time of disposal. Ingredient Hold Time Ingredient Hold Time Avocado 12 Hours Snowcrab 2 Days Carrots 3 Days Squid 2 Days Cucumber 2 Days Tempura Shrimp 2 Days Lettuce 3 Days Tuna 2 Days Sushi package 24 Hours Yellowtail 2 Days Sushi Rice(cooked) 24 Hours Cream Cheese 5 Days Spring Roll 1 Day Gyoza 3 Days Eel 2 Days Inari 5 Days Chicken 2 Days Sauces 5 Days Kani Stick 2 Days Seaweed Medley 5 Days Masago/Tobiko 2 Days Seaweed Salad 5 Days Octopus 2 Days Squid Salad 5 Days Salmon 2 Days Tamago 5 Days Shrimp 2 Days Wasabi 5 Days Brown Rice 48 Hours Ginger 5 Days Mango 2 Days lalapeno Crunch 5 Days Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA.01/04/2019 Confidential Property of Hissho Sushi Page )13 Refrigerator/Dry Items Shelf Life in Cooler/Dry(unopened) Shelf Life(Opened) Natural Mayonnaise 6 Months(Refer to BBD on Package) 21 Days Sriracha Mayonnaise (spicy sauce)/ Combined onsite• 5 Days Wasabi Mayonnaise Sushi Ginger 12 Months (Refer to BBD on Package) 30 Days Cream Cheese 120 Days (Refer to BBD on Package) 5 Days Hissho Vinegar 12 Months(Refer to BBD on Package) 30 Days Fried Onion 9 Months(Refer to BBD on Package) 30 Days Roasted Seaweed/Nori 12 Months (Refer to BBD on Package) 60 Days Soy Paper 12 Months(Refer to BBD on Package) 60 Days Rice Paper 12 Months(Refer to BBD on Package) 60 Days Wasabi Pea 12 Months(Refer to BBD on Package) 60 Days Sriracha Pea 12 Months (Refer to BBD on Package) 60 Days Lite Soy Sauce Packet 24 Months (Refer to BBD on Package) N/A Hissho Soy Sauce Packet 24 Months (Refer to BBD on Package) N/A Spring Roll Sauce Gallon Size 12 Months(Refer to BBD on Package) 21 Days Natural Wasabi 12 Months (Refer to BBD on Package) 12 Months Black Sesame Seeds (12 Packs/Case) 12 Months (Refer to BBD on Package) 60 Days Sesame Seeds (5 lb/pk—8pk/cs) 12 Months (Refer to BBD on Package) 60 Days Hissho Natural Sushi (Eel)Sauce (6 12 Months(Refer to BBD on Package) 30 Days bottles/case) Sriracha Chili Sauce 12 Months(Refer to BBD on Package) 30 Days Chili Oil (1 gal/jar;4 jar/case) 24 Months (Refer to BBD on Package) 90 Days Tempura (puffed rice) 12 Months 30 Days Uncooked Rice 12 Months(Cool, dry area&free of 60 Days pest contamination) Jalapeno Crunch 12 Months(Refer to BBD on Package) 5 Days Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 i Confidential Property of Hissho Sushi Page 114 ALLERGENS (FISH,CRAB, SHRIMP, SOY, MILK, EGG,WHEAT) Finished product labels must declare the presence of wheat, the type of shellfish, soy, egg, milk and the type of fish. Do not scratch out or write in ingredients on the label. Prepare foods which contain known allergens after all other products have been produced (spring rolls 4 cooked rolls -> raw rolls). Follow the sequence to prevent cross-contact.Wash hands thoroughly after handling known allergens. Do not change the recipe as this will not reflect what is listed on the ingredient label. • Do not use spicy mayo (egg) or sesame oil (sesame)to coat gloves for rolling sushi as these are allergens. • Use clean and closed containers for storing allergen ingredients (such as Spicy Mayo,Japanese BBQ Sauce, Crab, Shrimp and Types of Fish). Do not store different ingredients in the same container. Use a different container for each type of fish(Salmon,Tuna,Yellowtail, Eel,etc.) • Use the appropriate dispenser(pastry bag, squeeze bottle,shaker)to prevent cross contact of non-allergen ingredients). Do not reach into a bin of Wasabi or Sriracha Pea.Use the pastry bag or shake the product into your hand and sprinkle on the sushi roll. • Use the designated bamboo mat for rolling sushi rolls to prevent cross contact.They are identified with a V , „C„ „and R„ (Veggie,Cooked and Raw). • Conduct a thorough cleaning and sanitizing immediately after processing foods that contain allergens on cutting boards, equipment and knives. Sanitizer is not effective on allergens. They are removed by vigorously scrubbing the surface with hot, soapy water, followed by rinsing, sanitizing and air drying. • Do not put food on surfaces that have touched allergens. • In the event of offering samples,ensure the sampling card with allergen information is provided adjacent and in clear view of the samples. Do not offer samples with no allergens in the same container with samples that contain allergens. • Made-to-Order rolls may be prepared upon customer request after following these steps: o Ensure all ingredient containing-allergens are removed from work surface. o Vigorously wash in-use cutting board and sushi knife with hot, soapy water, rinse with warm water,sanitize. o While items are air drying,wash hands with warm,soapy water and change gloves. o Use designated bamboo mat and prepare sushi roll, package and verify label. . • Upon completion, vigorously wash cutting board, used equipment and sushi knife with hot soapy water, rinse with clean water, sanitize and air dry. Obtain designated bamboo mat and resume previous processing. Rewrap bamboo mat in the event that cross-contact occurs between allergens or allergens and non-allergen ingredients. • In the event of ingredient cross-contact, discard the ingredient that made contact with the allergen. • In the event of equipment cross-contact, vigorously wash the equipment in hot, soapy water, rinse with clean water, sanitize and air dry. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page115 5. PREPARATION OF SUSHI RICE Materials Needed x Rice Cooker Rice Paddle Scoop Manufacturer:THUNDER GROUP INC Model:SE1-50000T �P,,wo 77 k� Large Bin Container Measuring Cup pH Meter and 2-2 oz.cups 0 1'tiafta.�si crz+� o fl Scale Rice Hissho Sushi Seasoning (models vary based on market) 2.5%acidity Distilled Tap Water Water Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 116 Step 1 Verify rice cooker pot Is clean and in good ,� ; „ . -.•� repair N. Key Pis Rice Cooker *Clean *Good Condition dg 5 Why Y r . Dirty or damaged equipment car'harbor <° r bacteria and lead to foodbome illness Step 2 c-41, fi r* Add 7lbs.Rice to pot 1 Key Points 1.Place pot on scale 2.Add 7lbs.Rice to pot from clean undamaged container ire why? --14 Weight is used instead of volume for a more accurate recipe Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 117 Step 3 Wash rice three times Key Points 1. Visually inspect rice for physical r t contaminants 2. Agitate with clean gloved hands 3. Partially fill pot each time 4. Agitate with clean gloved hands S. Drain Water H My? To visually inspect rice and remove any debris that may be present T y Step 4 Add 8lbs.Water* <. *Take into account the water added during the washing process Key Points 1.Place pot on scale 2.Add 8lbs.From a potable water source taking into account the water added during the washing process 3.The total weight of rice and water is 15lbs. ".' Why? Weight is used instead of volume for a *. more accurate recipe Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 118 Step 5 Cook Rice for approximately 30 minutes Key Points 1. Depress button to begin cooking 2. Do not lift lid during cooking process 3. When rice is cooked the "Keep Wane"light will be on. Why Cooking helps kill any bacteria that may be present in the rice Step 6 Verify rice container is clean and in good repair Key Points Rice Container *Clean *Good Condition Why? Dirty or damaged equipment can harbor bacteria and lead to foodborne illness Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 119 Step 7 Place cooked rice in container v k � + Key Points 1. Use rice paddle to empty rice cooker 2. Layer of rice in container can not be greater than 2 inches in depth. a Why tX , „ Placing rice in a larger container speeds the cooling process and makes it easier to mix the sushi seasoning into the rice 40 Step 8 i Add 32oz.Hissho Sushi Seasoning (2.5%acidity) 4 a j Key Points 1. Measure 32oz,Sushi Seasoning 7 2. Pour Seasoning evenly across rice fi S _ ? Why? "T 32oz.Of Seasoning is added to acidify the F' • ;` , rice and add flavor. More seasoning may • , i �. be added if target pH(_4.1)is not reached. Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page I20 Step 9 ` Mix rice with Seasoning . . Key Points 1. Mix rice with rice paddle 2. Make sure all rice is evenly coated in seasoning } 3.Measure pH within 30 minutes of mixing. A IN r y? Evenly coating rice with seasoning • R, ,-,; ensures that all rice reaches the t appropriate pH(5_4.1) Step 10 Pour approximately 2oz.Distilled water into container this will be repeated one additional time Y Ke Points t. Pour distilled water into one } of two containers that are 2 s oz. in size loOK, 11Vh ? `= Distilled water is used to avoid H p h' fluctuations associated with local water r supplies Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page121 Step'11 Fill the other 2 oz.container with . five small rice samples from different areas of the container _ Key Points 1. Take five small samples,each comer and the center of.the rice container 2, As you take the samples place them into the other identical container t it Why? i � �• - '�' ... �:`;; III Five samples are taken'from different " r areas to makeup a representative sample for a more accurate read Step 12 Mix two parts distilled water with one part rice "The Health Department may require you. ` to use a blender. If:you are unsure whether you should use a blender,Please Contatct Your RCIRM** Key Points 1. Mix distilled water and rice.into slurry i with chop sticks or other clean utensil T . Why? 71 1 4 two parts of distilled .water and one part rice are mixed together in order to get a liquid so that we can test the pH Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page122 Step 13 1 Pour the mixture into a container ,a Key Points P. 1.It helps remove most of the vinegar from inside the rice. 2.It helps cool the mixture. — Why? h For an accurate reading the product needs to have its pH reading taken roughly at room temperature. a It also helps guarntee that the proper pH controls are being met. Step 14 Please calibrate the pH meter(see page 31). Place the pH meter,that is in calibration,into the cup. G ; t J G Key Points T 1. Turn on pH meter 2. Place calibrated pH meter intothe cup F 3. Record reading once the stability icon n is displayed at the top left of the display t 1, 4. Verify reading is between pH<4.1 4 } 5. If reading is above the required range add more Sushi Seasoning and repeat steps 10-14. Record the reading in the corrective action portion of the Sushi Rice H Log. Why? *Critical Control Point* t A pH of 4.1 or below is used to control a bacteria and must be strictly followed or `' someone may become sick from our .`t product .�, Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 123 Step 15 Sushi Rice is ready for the next step Key Points 1. pH must be<_4.1 before proceeding to the next step R 2. Layer of rice in container can not be greater than 2 inches in depth. n Why . .. °< pH was verified and now rice can proceed to the next step Step 16 Sushi Rice has a 24 hour shelf life Key Points 1. Once the rice is acidified, it is then considered shelf stable. 2. Discard the acidified rice after 24 .. hours. ems: —Do—nof use sushi rice that is>4:1: =y If pH remains >4:1 after adding g 12 more oz. of susfii seasoning, discard. Why? i'ry ti ym�, u > A 24 hour shelf life of sushi rice is used to ensure quality. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page124 5A. PREPARATION OF BROWN SUSHI RICE -TIME &TEMPERATURE CONTROLLED 1. Weigh and place 4 lbs.of brown rice in an empty rice pot. 2. Wash and scrub the rice cold water at the food preparation sink for at least 3 minutes.The rice must be scrubbed to scratch the outer coat of the grains. 3. Weigh and add 8 lbs.of water to the rice pot. 4. Cook the rice in the rice cooker for 1 hour and 30 minutes. 5. After the rice is finished cooking,transfer the rice into an NSF®shallow container.The rice may not be stored any more than 2 inches high inside the container.Spread the rice into a flat even layer. 6. Pour 16 oz.of vinegar evenly across onto the rice and thoroughly mix the rice and vinegar with the rice paddle to evenly coat. 7. DO NOT COVER! 8. Mix the rice every 10 minutes until the rice reaches an internal temperature of 135°F. 9. Using a calibrated thermometer,measure and record the time the rice reaches 135°F. 10. After the rice cools to 135°F,place the container of rice into cooling equipment such as a cooler or freezer • Do not cover the container!The lid must remain off in order for the rice to properly cool. • For locations that require for all food to be covered regardless of whether it's cooling or not: Place plastic wrap on top of the container of cooling food and poke enough holes all over the top of the plastic to allow the steam to escape and for proper airflow.Do not place a solid plastic lid over the container. 11. Using a calibrated thermometer, measure and record the time when the rice reaches 70°F, it should be 2 hours or less from the time that the rice reached 135°F. 12. Using a calibrated thermometer,measure and record the time when the rice reaches 41°F or below,it should be 4 hours or less from the time the rice reached 70°F.You may use the rice or place a lid onto the container after it reaches 41°F or below and place it into cooling equipment. 13. The cooling process must be monitored the entire time.You may not prepare rice in the evening and leave it in the cooler to cool overnight,this is not monitoring. 14. Label the container with the rice pot#,product name and use by date and time.Your rice must be used up or discarded within 48 hours from the time the rice reached 41°F. 15. Brown sushi rice is controlled by temperature;so only bring out enough rice necessary for preparation.Each roll takes 2 minutes to prepare. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 r Confidential Property of Hissho Sushi Page125 6. RECIPES Half Pot White Rice • Rice—3.5 Ibs • Water—4lbs • Cooking time—45 minutes • Vinegar—16 oz(2 cups) • Acidity for sushi rice:<_4.1 Brown Rice • Brown Rice—4lbs • Water—8lbs • Cooking time—1 Hour and 30 minutes • Vinegar—16 oz After mixing the rice with vinegar,the rice needs to cool down below 70°F in the first two hours.Then,it needs to be below 40°F in four hours. Multi-grain Rice • Multi-grain Rice—1lbs • White Rice—2lbs • Water—4.51bs • Cooking time—1 Hour and 30 minutes • Vinegar—12oz After mixing the rice with vinegar,the rice needs to cool down below 70°F in the first two hours.Then,it needs to be below 40°F in four hours. 7. FOOD SAFETY HAZARDS Sushi becomes unsafe when it is contaminated by harmful substances or microorganisms.There are three main types of food safety hazards. • Biological:Bacteria,viruses,parasites and fungi. • Chemical:Pesticides,cleaning supplies or toxics that get into food. • Physical:Foreign matter like hair,dirt,bandages,metal staples,or broken glass,etc.that gets into food. Sushi can also become unsafe through cross-contamination; the transfer of harmful substances or micro-organisms from one source to another. An example would be when raw fish is stored above a ready to eat product and fluid drips from the fish onto the other product. Your product can also become contaminated when you do not do a good job of cleaning and sanitizing food contact areas.These are food contact surfaces such as cutting boards.These surfaces must be cleaned (free of visible soil) and sanitized(free of harmful levels of contamination),when changing from raw to cooked items,after using seafood, or every 4 hours or when needed. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Ir Confidential Property of Hissho Sushi Page 126 8. HACCP PLAN Hissho Sushi's 2018 HACCP plan was reviewed and validated on January 4, 2019 by the below members to ensure accuracyof the Ian. This Ian will be reviewed annually. P P HACCP Team Title Signature Qualification Member Food Safety Field Seafood HACCP Krrtika Shakya , Inspector Certified Soe Naing Kyi Director of Seafood HACCP Operations-West ! Certified Director of Seafood HACCP Hsiao Wen Procurement Certified Director of Yuan Edna Wang Corporate Seafood HACCP Development and Certified Strategy Sushi Bar Location: Document: Sushi Bar SSOP S:\Compbance\SSOP & HACCP\MA Version: MA 01/04/2019 I Confidential Property of Hissho Sushi Page 127 Flow Chart Receive Receive Receive Dry Refrigerated Frozen Goods IF IF Place Place in Place in in Refrigerated Frozen Dry Storage Storage Prepare Gather Thaw Sushi* Utensils Frozen and � Critical Limit:pH of 54.1 See page 9 Prepare Sushi DHold Package Sushi Cool Sushi* Display *Critical Control Point Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 0 0 c 3 m HACCP Members: Toinette Waldon Vivian Huang t/1 C �+ Yuan Wang Soe Naing Kvi Cu HACCP Plan:Prepare and Distribute Sushi Process HACCP Product Description n O o Describe Product: Raw and/or are-cooked seafood,with or without raw vegetables,with or without sauces,with acidified h rice,with or without wrapper CL M i Describe_Packaging: Sushi rolls are placed in plastic.tray and covered with an oxygen permeable lid 3 t� '•r 0 Shelf Life,at What Temperature: 24 HR.Shelf life at 41°F or less y' 3 — �• Product Characteristics: Short shelf life:fresh,raw and/or cooked ingredients Labeling Characteristics: See sample label in supporting documents o i M L^ Ingredients/Raw Material: See label ingredients in supporting documents m O a Special Flavorings and Toppings: Depends on variety:see label ingredients in supporting documents c 90 = Distribution Controls: Directly to general public-in refrigerated display case or non-refrigerated vehicles with coolers and non- 0 D [7 toxic ice blankets f7 = yIntended Use s 0 Product Use: Sushi Rolls are prepared products(ready-to-eat)to be consumed raw cn c < Intended Consumer: General Public `^ M S Method Sold: Retail out of display case in covered plastic trays O Consumer Expectations: Fresh raw and/or cooked ingredients with acidified rice D 0 N V o a+ ua � ro N O 1-" N l0 00 0 0 r) c 3 CD N C N S 03 Hazard Analysis Worksheet HACCP Plan: Process and Distribute Sushi Process can Last Reviewed:01/04/2019 r) C' o O Product Description:Sushi,sold at retail for consumption to the general public c. N fD 3 OProcess Step Potential Hazards Are any of the Justify the decision What control measure(s)can be applied Is this step a Critical -F 3 potential food safety to prevent significant hazards Control Point? a, �• hazards significant? Receiving Physical:Rocks, No Shipments inspected'upon receipt C Insects,Wood .a �^ Food Storage Physical:Insects No Regular cleaning performed rD N O and Rodents v Food Storage Biological: No Fish kept refrigerated 90 Histamine Toxin o 2 D Preparation Physical:Insects No Regular cleaning performed and rice �" nand Rodents inspected prior to cooking __ i Preparation Biological: Yes Serious illness could occur if the rice is not Acidify Rice within 30 minutes Yes LA Bacillus cereus acidified D S Preparation Physical:Plastic No Rolls inspected during packaging portion of o and Paper the preparation process N Preparation Biological: No Preparation time is brief Histamine Toxin (A Cooling Biological: Yes Pathogens can grow under temperature Product rapidly cooled to 41°F or less Yes —' O Pathogen Growth abuse conditions and cause illness within 4 hours Display Biological: No Rolls kept refrigerated Histamine Toxin, D Pathogen Growth O O � P Co N M O � lND v 0 r) c M HACCP Plan Form .. Firm Name: Hissho Sushi Product Description:Prepare and distribute sushi process C Method of Storage&Distribution Stored and'distributed refrigerated in Ln oxygen permeable packages _? Intended use&Consumer Prepared product ready-to-eat,to be consumed by general public. W _ Critical Control Signilicant Critical Limits for each Monitoring Corrective Action Verification Records N Point(CCPi Haxerd(s) Control l7 (,n Measure What How' Frequency Who. o 0 0 Rice Pathogenic pH of rice pH meter Each batch after Trained pH meter Sanitation- 3 Acidification bacteria growth pH of rice is 4.1 or less after mixing acidification Sushi Chef If the pH is not 4.1 or less,then add more vinegar and re- calibrated for Operation ~ —temperature with vinegar or Employee check the pH.Evaluate rice acidification formula to each batch Log I d CA abuse.(Bacillus prevent future recurrences. daily and rD cereus) recorded on the Lab 3 OSanitation— validation Operation Log. updated 3 The pH Will be annually or _ recorded in the when tL pH log section recipe : by sushi chef modified/ O C) rD and reviewed N monthly by (� Hissho Mgmt. fD � Doling Pathogenic internal temperature of Product temperature Probe-type Every batch Sushl Chef If product temperature.is>41°F/5°C after 4 hours,discard. Cooling log Sanitation! ,y, bacteria growth 41°F15°C or less within 4 thermometer section of Operation ,C 90 —temperature hours Sanitation— Log = abuse. Operation Log' 0 D reviewed ~' (� monthly by _ [7 -Hissho frigmt _. / to D 0 0 < _ rD I CA. 0 Z D O o v 4�b 0° N M O W t0 0 Confidential Property of Hissho Sushi Page 131 9. THERMOMETER CALIBRATION DIAL THERMOMETER CALIBRATION • You will need a 50/50 mix of ice and water. • Place your thermometer into the ice water. • Take the reading once the dial/reading stays put. • If it reads 32 degrees F it is calibrated. • If it doesn't read 32 degrees F adjust the hex nut under the dial to get a 32 degree F reading. • Make note on the temperature log every time you calibrate,because calibration is a corrective action. THERMOWORKS DIGITAL PROBE CALIBRATION END-POINT SENSOR THERMOMETER) • You will need a 50/50 mix of ice and water. • Place your thermometer into the ice water. • Take the reading once the reading stays put. • If it reads 32 degrees F it is calibrated. • If it doesn't read 32 degrees F then remove the Phillips head screw on the front panel. • Place a suitable flat head screw driver onto the screw hole and adjust the potentiometer to display 32 degrees F. • Make note on the temperature log every time you calibrate,because calibration is a corrective action. 10. PH METER CALIBRATION (HANNA HI 98127 WATERPROOF PH METER • pH meter calibration must be done every day. • Please make sure the expiration dates of the pH buffer solutions must be checked before using for calibration of the pH meter. • Pour each pH 7 and pH 4 buffer solution into separate 2 oz.cups and label. r • For normal measuring mode,press and hold the MODE sa button until OFF on the secondary LCD is replaced by CAL. • Release the button.The LCD enters the calibration mode displaying"pH 7.01 USE". • After 1 second the meter activates the automatic buffer recognition feature. • If a valid buffer is detected then its value is shown on the primary display and REC appears on the secondary LCD. • If no valid buffer is detected,the meter keeps the USE indication active for 12 seconds,and then it replaces it with WRNG,indicating the sample being measured is not a valid buffer. • Place the electrode in pH 7.01 buffer. After the first calibration point has been accepted, the "pH 4.01 USE" message appears. • The message is held for 12 seconds,unless a valid buffer is recognized. If no valid buffer is recognized,then the WRNG message is shown. • If a valid buffer is detected,then the meter completes the calibration procedure.When the buffer is accepted,the LCD shows the accepted value with the "OK 2" message, and then the meter returns to the normal measuring mode. *Ph buffer solutions must be marked with the manufacturer's expiration date. Check expiration date before using buffer solution for calibration. • When not in use,rinse the electrode with water to minimize contamination and store it with a few drops of storage (HI 70300)or pH 7(HI 7007)solution in the protective cap after use. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 132 10 A. PH METER - EXTECH PH100 METER EXSTIK 1. For new meters,remove the battery cap then remove the battery insulating strip. 2. Remove the cap from the bottom of the ExStikTM meter to expose the electrode probe. 3. Before first use or after extended storage,soak the electrode(with its cap removed)in the pH 4.0 buffer solution for about 10 minutes. 4. White crystals may be present in the cap.These crystals will dissolve in 4.0 buffer or it can be simply rinsed with distilled water. 5. A sponge is located in the electrode protective cap. Keep this sponge soaked with a pH 4.0 solution to preserve electrode life during storage. HOW TO CALIBRATE: 1. pH meter calibration must be done every day. 2. Please make sure the expiration dates of the pH butter solutions must be checked before for calibration of the pH meter. 3. Pour each pH 7 and pH 4 buffer solution into separate 2 oz.cups. 4. Pour distilled water into a 2 oz.cup and place in between of the buffers. ! 5. Turn on pH meter. Place the electrode into a pH buffer 7.0 solution and press the"CAL"button. 4f 6. The ExStikT" automatically recognizes the solution and calibrates itself to that value. 7. During the calibration,the pH reading flashes on the main display. 8. When calibration is complete,the ExStik'm automatically displays "END"and 0will appear on the display. It then returns to normal operating mode. 9. Rinse the electrode by dipping the electrode in the 2 oz.of distilled water. 10. Place the electrode in pH buffer 4.0 solution and press the"CAL"button. 11. The ExStiklm automatically recognizes the solution and calibrates itself to that value. 12. During the calibration,the pH reading flashes on the main display. 13. When calibration is completed, the ExStikTm automatically displays "END" and O will appear on the display. It then returns to normal operation mode. 14. The pH meter is now ready to measure. 15. Place electrode in sushi rice slurry.Document reading in log book. Reset: If the meter will not calibrate or displays a-1,reset the meter and attempt to re-calibrate. 1. Turn off meter. 2. Remove the battery cartridge from the top of the meter. 3. Press the On/Off button for 10 seconds 4. Re-insert the batteries,power on the meter and attempt to re-calibrate the meter. Ph buffer solutions must be marked with the manufacturer's expiration date. Check expiration date before using buffer solution for calibration Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 133 11. LOGS Logs are used to monitor opening and closing procedures, pH of sushi rice,temperature, receiving and delivery (at select locations). The logs are completed daily by the Sushi Chef and will be maintained at the sushi bar, and held for at least 30 days for monthly verification by the Regional Coordinator,as part of the HACCP monitoring plan. VERIFICATION Verification means the monitoring and corrective actions were complete. • Logs are reviewed and signed by the person in charge. • A verifier(a Hissho Sushi Field Representative)will verify your logs during a routine inspection. RECORD KEEPING At least one year worth of food temperature and pH logs must be available for review at the sushi bar.Logs must be stored in chronological order in a neat and order manner. It is highly recommended that you keep at least 2 years'worth of logs at home. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 v 0 Daily Sanitation/Operation Log Date: CD Start Each Shift With: r0r 1. Hands Washed&Afuuy supplied hand washing station White Rice pH Measurement' (n 2., Sanitizer bucket with 200 ppm of sanitizer C 3. Calibrated thermometer,pH meter&`available log n Time p Time p pH eter Ime Inrtla ea Ing H 4. Bamboo mats wrapped in lactic of Rice Measured Calibrated: Rice Is All if pH is>4.1. pP p Cooked 7.0/4.0 Used oWj Insert TIME in top column&INITIAL after each task is completed Batch 1 Ln N Daily Cleaning Batch 2 n 0 Equipment Start Time: 4 Hours: 4 Hours: End Time: Batch 3 O 3 AM AM PM PM Batch 4 ~` Orderly:Clean and sanitize tables, a. V1 countertops,sinks..Clean all work surfaces BdtChS M / All utensils,cutting boards,bamboo mats, - 3 n pans properly cleaned&sanitized;proper e- Record time rice is cooked.Rice pH is measured within 30 minutes after mixing&must be between 3.8-4.1 'y O • If pH>4.1,add 8-12 oz.of vinegar,retake pH and record in the"2nd Reading"column —• concentration • pemrvl Time rice is ucwd rin nr discarded Personal health,hand washing practices, — glove use,proper hair covering,no jewelry, clean and maintained outer garments Brown/Quinoa/Multi-Grain Rice Cooling 0 All food dated,;protected and labeled Type of Time Rice Time Rice.: Time Rice Rice Discarded Initial rD O / properly Rice Reaches 1357 Reaches 70`F Reaches 417 Yes/No -O N Proper storage and labeling of chemicals Batch 1 Ln .and cleaning items z -0 Shelves,display cases,.refrigerators and Batch 2 &-o operating Properly N P 8 P P riy QO freezers clean order Step 1:DO NOT COVER"WITH LID: Record the time rice cools to 135°F _ :Clean floor,drains&trash can, Step 2:Record the time rice cools from 135°F to 70°F(must cool in 2 hours or less) 0 remove trash Ste 3:Record the time rice cools from 701 to 41°F must cool in 4 hours or less D P ( ) [7 Calibrate Thermometer Daily(32`F) *Rice is discarded if cooling times in Steps2 and are not met = j (and if dropped or mishandled) Time: Initial: Packaged Sushi Coolingt(coolwithin 4 hours)' v, N D #of Packages Time Start Time End Out Temp Discard :Initial � Internal Temperature of Temp/Time Temp/Time Temp/Time Yes/No O Food Morning Afternoon Evening "F 7 Sushi Display Case F "F "F =F CD N_ Cold Top/Prep Cooler "F 7 "F -F — O Reach-in Cooler "F "F "F 'F Walk-in Cooler "F "F "F "F Freezer, •F °F •F D Inkial: C Corrective Action: 0 Supervisor Signature: Date: tro N M C:) I-A W Confidential Property of Hissho Sushi Page 135 Store Name/Number: Hissho DPR Sunday Monday I Tuesday Wednesday Thursday Friday Saturday Item Day E-L M-L Day E-L AI-L Day E-L N1-L Day E-L b1-L Day E-L AI-L Day E-L bI-L Day E-L AUL Ocean Spring u Spring Roll Mini Nagano ti Tuna Poke Spicy Inari Blazing Cali California Roll California(Br) Dynamite Roll Eel Roll Hissho Healthy Healthy(Br) y Nippon Favorite Nippon(Br) Philadelphia Roll Snow Crab Roll Spicy Roll Sushicado Sushicado(Br) Spicy Roll Spicy Roll(Br) Veggie Roll Veggie Roll(Br) Southern Charm Crunchy Shrimp Crispy Crab Caterpillar Roll Living Color Roll Man o Tango Outer Banks a Rising Sun Roll d Salmon Lover a Sashimi Sriracha Party Tempura Shrimp TNT Wasabi Crunch H Hissho Spicy d Special Cooked 0 Sushi Lover Nagano Special o Sashimi U Maui Bento $4.99 u $5.99 rn$6.99 w s $7.99 U $11.99 Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 136 Lwih Family Co.dha Hissho Sushi Steele Creek Rd.Chad �ISS�Q�. Charlorie-,NC 28273 tv� i� LW Receiving Log Description and TimelTemperaturei Accept? Date Referigerateds41T Initials Check if Corrective Action Invoiceit Frozen<_0°F Yes El El El El EJ Form:FS-REC-1 SA7ood Science\Forms\FS-REC-1 Version:01-2011 Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page137 Version:3/15/2015 Delivery Log Date Delivery Location Loading Time Adequate Delivery Time. Initial Delivered to Corrective Action Ice Signature Blankets? Y/N Temp"F Temp°F • The internal temperature of finished product must be 41°F(5'C)or less prior to loading in the cooler and when delivered to location • Record the time and temperature In"Loading"and"Delivery"columns • Use"1-2"method when loading cooler:1 ice blanket—2 rows of packaging-1 ice blanket • Store coolers and Ice blankets in walk in freezer for next day's deliveries Verified: Date: Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 138 12. LABORATORY ANALYSIS OF SUSHI RICE oa Page 1 of 1 d o o m o 3 1-B Foodmart Road•Boston,MA 02118 moo 0 e Tel:617-269-6424.617-268-0971 •Fax: 617-268-1635 Certificate of Analysis January 14,2019 HISSHO SUSHI 11949 Steele Creek Road Report 4.17895 Charlotte,NC 2 8 2 7 3 Samples Received: January 8,2019 Attn: Ryan Kang Drop off Time: 11:00 AM AFL 4 Sample Description Test Procedure(s): TEST DATE: Amhient TIME: pH Temperature 426824 1/8/2019 20°C-25°C 12:00Noon 3.98 42682-2 11812019 20°C-250C 1:00PM 4.01 42682-3 1.1812019 20°C-25°C 2:OO PM 4.02 42682-4 1/8/2019 200C-250C 3:OO PM 4.04 42682-5 11812019 200C-250C 4:00 PM 4.00 42682-6 11812019 20°C-250C 5:00 PM 4.01 42682-7 11812019 200C-250C 6:00 PM 4.02 42682-8 11812019 209C-250C 7:00 PM 3.99 42682-9 11812019 200C-250C 9:OO PM 4.03 42682710 SUSHI(White Rice) 11812019 20°C-25°C 10:00 PM 4.00 42682-11 Prepared in Boston 11812019 20°C-25°C 11:00 PM 4.01 42682-12 11812019 20°C-250C 12:OOAM 4.00 42682-13 11912019 200C-250C 1:OOAM 4.04 42682-14 11912019 200C-250C 7:00AM 4.00 42682-15 11912019 200C-25PC 8:OOAM 3.98 426827.16 11912019 20°C-25°C 9:OOAM 4.03 42682-17 11912019 20°C-25°C 10:OOAM 4.01 42682718 11912019 20°C-25°C 11:OOAM 4.03 42682-19 11,912019 2.0°C-25.°C 12:00 Noon 4.00 42682-20 11912019 20°C-25°C 1:00 PM 4.00 Method: AOAC 981.12 ilc A uilar l U ratq�y Anal s[ Advanced Food Labs maintains accreditation in accordance to ISO/(EC 17025:2005 for the specific tests listed.in PIlA Certificate 4 L16-474. The data and other information contained on this document represent only the samples analyzed and are rendered upon the condition that they are dot to be reproduced wholly or in part for advertising or other purposes without written permission from the laboratory. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page139 13. EMPLOYEE HACCP TRAINING PROCEDURE All employees receive HACCP training at Hissho Sushi's corporate headquarters in Charlotte,NC prior to beginning employment and annually after that. Chefs are trained on identification of processes that are critical control points, how these processes are to be monitored,and what corrective actions must be taken when critical controls are violated. The approved HACCP plan will be available in the sushi bar at all times. Employees also receive training on Hissho Sushi's SSOP's which include important practices such as employee health,hand washing procedures,proper cleaning and sanitizing,pest control,proper flow of food,food safety hazards,use and calibration of a meter stem thermometer and pH meter. Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 r Confidential Property of Hissho Sushi Page140 14. COMPANY ILLNESS REPORTING AGREEMENT Food Employee Reporting Agreement Preventing Transmission of Diseases through Food by Infected Food Employees The purpose of this agreement is to ensure that Food Employees and Applicants who have received a conditional offer of employment notify the Person in Charge when they experience any of the conditions listed so that the Person in Charge can take appropriate steps to preclude the transmission of foodbome illness. I AGREE TO REPORT TO THE PERSON IN CHARGE: SYMPTOMS 1. Diarrhea 2. Fever 3. Vomiting 4. Jaundice S. Sore throat with fever 6. Lesions containing pus on the hand,wrist,or an exposed body part (such as boils and infected wounds,however small) MEDICAL DIAGNOSIS Whenever diagnosed as being ill wiith Norovirus,Salmonella Typhi(typhoid fever),Shigella spp. (shigellosis),Eschedchia coli 0157:H7,hepatitis A virus,Entamoeba histolytica,Campylobacterspp., Vibrio cholera spp.,Cryptosporidium parvum,Giardia lamblia,Hemolytic Uremic Syndrome,Salmonella spp.(non-typhi),Yersinia enterocolitica,Cyclospora cayetanensis or any other disease transmissible through food so designated by 105 CMR300.000 as reportable. PAST MEDICAL DIAGNOSIS Have you ever been diagnosed as being ill with one of the diseases listed above? If you have,what was the date of the diagnosis? HIGH-RISK CONDITIONS 1. Exposure to or suspicion of causing any confirmed outbreak of typhoid fever,shigellosis,E.coli 0157:H7 infection,or hepatitis A 2. A household member diagnosed with typhoid fever,shigellosis,illness due to E.coli 0157:H7, norovirus or hepatitis A 3. A household member attending or working in a setting experiencing a confirmed outbreak of typhoid fever,shigellosis,E.coli 0157:H7 infection,or hepatitis A I have read(or had explained to me)and understand the requirements concerning my responsibilities under 105 CMR 690/1999 Food Code and this agreement to comply with the reporting requirements specified above involving symptoms,diagnoses,and high-risk conditions specified. I also understand that should I experience one of the above symptoms or high-risk conditions,or should I be diagnosed with one of the above illnesses, I may be asked. to change my job or to stop working altogether until such symptoms or illnesses have resolved. I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the food regulatory authority that may jeopardize my employment and may involve legal action against me. Applicant or Food Employee Name(please print) Signature of Applicant or Food Employee Date Signature of Permit Holder or Representative Date This is a model form created by MA Dept.of Public Health which is offered as a tool for industry to use to aid in compliance with 105 CMR 590.003(C)and Food Code 2-201.11 The use of this form is voluntary and is not required by state regulation. Revised:5/8r2001 Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page141 RESPONDING TO A FOOD-BORNE ILLNESS COMPLAINT Policy:The sushi chef will respond to a complaint of a foodborne illness promptly and will show concern for the individual making the complaint.The complaint is referred to their regional manager/supervisor for further investigation. Procedure:When a complaint is received related to a foodborne illness,sushi chef/franchisee and/or helpers will take the following steps. 1. Indicate concern for the individual and let that person know that the complaint will be investigated and referred accordingly. 2. Talk with the individual making the complaint. Get basic information required to complete a written report (name,contact information, product consumed, illness experienced). 3. Refer information to your regional manager/supervisor. 4. Regional manager/supervisor will forward information to their Hissho Sushi corporate supervisor, Directors' team and store manager. Headquarters office will obtain additional information from complainant(date of consumption,onset of illness, physician visit,etc.).The complaint is logged and reviewed by headquarters to determine if other complaints have been received The regional manager/supervisor will visit the location to: 1. Determine if co-workers/employees and immediate family have experienced illness(vomiting, diarrhea, jaundice,sore throat). 2. Verify refrigeration practices and equipment are functioning properly. Discuss with store management of recent power outages and submitted maintenance requests. 3. Review logs to ensure pH measurements and temperatures are compliant. 4. Evaluate receiving practices (time frame of receipt and working the palette). 5. Assess delivery practices if location is a "delivery location"only. 6. Review and verify all ingredient sources are from or approved by Hissho Sushi. This is done by reviewing all invoices, ingredient containers and shipment dates. Evaluate date marking procedures of food ingredients. 7. Evaluate chef/franchisee practices are minimizing cross contamination. The health and hygiene of all chefs/franchisees is extremely important in ensuring that Hissho Sushi is the best sushi bar in every region. Below is a basic guideline in dealing with the health of all chefs/franchisee as it relates to diseases that are transmissible through food. All chefs/franchisees are to notify their regional manager/supervisor and the Hissho Sushi Compliance team if they have been directly or indirectly exposed to a reportable illness. If a chef/franchisee family member has been diagnosed with any of the following reportable illnesses, he or she will be excluded from work and will need a written medical release from a physician to return to work.All new hire chef/franchisee must notify the Compliance team and Hissho Sushi Corporate Headquarters if they have ever been diagnosed with or exposed to a reportable illness prior to starting work. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 142 Illness Symptoms Prevention Illness Symptoms Prevention Norovirus Proper hand washing,good Vomiting,diarrhea,abdominal hygiene, no bare hand contacting cramps,nausea, low grade fever ready-to-eat food Hepatitis A Fever, nausea,vomiting, Proper hand washing,good abdominal, pain,fatigue,swelling hygiene, properly handle raw of liver,jaundice seafood Shigella spp. Diarrhea,fever,abdominal Proper hand washing,good cramps,dehydration hygiene, properly cook foods Shiga-toxin producing Proper hand washing,good Escherichia coli Bloody diarrhea, kidney failure hygiene, properly hand&cook foods Salmonella Typhi Nausea,fever,vomiting, Properly cook food,avoid cross abdominal cramps,diarrhea I contamination A chef/franchisee that reports an intestinal illness,flu-like symptoms or lesion (open and draining) may be excluded from work or assigned to restricted activities that do not involve contact with food. In addition, the chef/franchisee reporting these conditions must not handle food or have contact with clean equipment, utensils, linens, or single-service items. intestinal illness or flu-like symptoms include the following conditions: Nausea*Sore throat/coughing with a fever*Vomiting *Diarrhea *Jaundice The guidelines mentioned above are not intended to be all inclusive of communicable diseases, but rather a list of illnesses that are known to be transmissible through food. If you have questions,please call the Hissho Sushi Compliance Team at(704)926-2293. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 143 15. CLEANING & DISINFECTING PROCEDURE Cleaning and Disinfecting Procedures Resulting from Vomiting and Diarrheal Events Due to the highly infectious nature of Norovirus,cleaning and disinfecting procedures in accordance with Clean-up of Vomiting and Diarrheal Events are as follows. Supplies: Personal protective equipment(PPE) Cleaning supplies 2 pairs of disposable,non-latex gloves 1 sealable,plastic bag or biohazard bag 1 face mask with twist tie 1 disposable apron 1 scoop/scraper 1 disposable hair cover Disposable paper towels or absorbent 1 pair of shoe covers powder/solidifier Disinfectant Procedures for cleaning and disinfecting: 1. Remove sick individual(s)from establishment. 2. Restrict access to the area with items such as cones or caution tape,only allowing access by designated employee. 3. The designated employee must put on PPE and gather cleaning supplies. 4. Cover the spill with absorbent material to soak up all fluid. 5. Scoop materials into sealable bag. 6. Apply disinfectant to surface(food and non-food contact)using a disposable towrel or spray bottle and allow a contact time of at least 5 minutes.If used on food contact surface,wash,rinse and sanitize surface after disinfectant has dried to remove any residue. 7. Discard any food products and single-service items possibly exposed to the airborne droplets from body fluid,as far as 25 feet from the incident. 8. Disinfect any tools used in cleaning of event like mops or buckets. 9. Consider repeating the disinfection process to ensure removal of Norovirus particles. 10. Remove PPE prior,to leaving area and dispose of in scalable bag. 11. Properly wash hands,and if possible,shower and change clothing. You must keep an clean-up kit in stock at all times.In the event that the clean-up kit is used,please reorder a new kit as soon as possible. Ver.5/9/17 Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 144 16. GUIDE TO TAKING CALLS FROM THE MEDIA Rug oe Guide to Takin,g Calls From the Media stagy Caim Ask Questions` -Grab a pen and-paper and ask this information: ( Re'porter's name L `ir. Media outlet (TV.`station,newspaper radio) ill. Phone numberand email address: iu,.Deadline(when do they need the'iinformatron,by?), IMPORTANT Take:Your'Time Don't answer questions right ANay.Take the.reporter's informatt.97and.someone from.HQwill contact.them. Pleas take fheir.name, media'outlet and;phohenumber, i 6 a• S a ♦ a • .. Contact ♦ 'm "Call Hissho S'pshl Corporate Headquarters: a a . ♦.- at.704-g26-22:00.to.eg.i.ve.them the 0& that you gathered. Document: Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 Confidential Property of Hissho Sushi Page 145 17. PARASITE DESTRUCTION LETTERS Document:Sushi Bar SSOP S:\Compliance\SSOP & HACCP\MA Version: MA 01/04/2019 AMERICAN EEL DEPOT CORP. 405 MINNISINK ROAD TOTOWA, NJ 07512 �� W W TEL: 973-890-8898 FAX:973-890-8880 W .EELDEPOT.GOM r r i GUARANTEE LETTER Jan.1,2019 The Valid Date: Dec.31,2019 To Hissho Sushi Dear Sir or Madam: This is to certify that all the fish and fishery products including unagi(eels)products we supply to you have been inspected, and have been approved,for the food safety, and for human consumption by the U.S.Food and Drug Administration. The products have been stored at 18°degrees Fahrenheit or lower for more than 30 days aggregately. We also certify that our suppliers including our own factory,Changle Pacific Food Co., Ltd.operate in accordance with all applicable food regulations, such as, the U.S.Food and Drug Administration(USFDA) regulations addressing "Procedures for the.Safe and Sanitary Processing and Importing of Fish and Fishery Products(21 CFR Parts 123 and 1240), Requirements for Food Safety Management Systems(ISO 220001005), the guidelines of National Advisory Committee for Microbiological Criteria for Foods, and Codex Alimentarius,the.European Union. We assure you that all the products we supply to you are kept well within the temperature requirement specified upon Hazard Analysis Critical Control Point(HACCP)through out the entire chain of supply. We guarantee our Unagi products are"fully cooked"and"ready-to-eat". We really appreciate your interest on our products. We look forward to hearing from you. Please feel free to call us or e-mail us should you have any questions. Sincerely yours, Ricky Huang CEO American Eel Depot Corp. FDA Registration Number: 18006557182 A S-E4 104M-6 loop 01/01/2019 Dear Hisso Sushi: Re: Parasite Destruction Compliance Letter for, •Yellowfin Tuna (Thunnus albacares)Saku •Tuna (Thunnus albacares)Ground TS/CO treated •Tuna(Thunnus albacares)Loins TS/CO treated Please be advised that Western United Fish Company Dba Annasea Foods Group operates under FDA's Seafood HACCP regulations for all fresh and frozen seafood products,and steps have been taken to ensure our processes and procedures are compliant with FDA's HACCP regulations 21 CFR Part 117 and 123. Parasite in fish possesses human health hazard if consumed uncooked,undercooked,or unfrozen.As a reassurance to our customers, Western United Fish Company Dba Annasea Foods Group has implemented the following treatments guidelines to effectively control and destroy parasites in our frozen products,as well as reduce the numbers of potential parasites in our fresh products: 1. Belly flaps are trimmed off to reduce the number of parasites; 2.Freeze and store products at-4°F(-20°C)or below for a minimum of 7 days; 3. Freeze at-31°F(-35°C)or below until solid and store products at-47(-20°C)or below for 24 hours. As the intended use by our customers cannot be known,Western United Fish Company Dba Annasea Foods Group has developed a HACCP Plan with the assumption that all of our raw products sold would be consumed raw,as well as cooked. If the product is intended for raw consumption,please refer to the treatment guidelines 1-3 above to insure the parasites are destroyed. Please keep this compliance letter on file for 2019 should your customers or health officials request it. Please feel free to contact me if you have any questions at wicks@annasea.com or at 425.558.7809. Sincerely, John Wicks Operations Manager {�4495' E�0119 41 s Certificate of Compliance 01/01/2019 Dear Hisso Sushi, This document certifies that Western United Fish Company DBA Annasea Foods Group procures, processes and ships fresh and frozen raw to-be-cooked or ready-to-eat seafood products in accordance with FDA,WSDA, USDC's guidelines for food safety and quality.We assure that we have taken necessary steps to produce our products in compliance with FDA's 21 CFR 123 Seafood HACCP,21 CFR 117 Current Good Manufacturing Practice, Hazard Analysis,And Risk-Based Preventive Controls For Human Food, and Food Safety Modernization Act(FSMA)Preventative Controls regulations. We are dedicated to continuous improvement of our process and have been accredited to SQF Level certification.We have conducted Hazard Analysis and implemented HACCP plan for every line of item,which is reviewed and validated annually. We operate under the following Pre-requisite Programs: • Good Manufacturing Practices •Allergen Control Program that includes labelling declaration of presence of any allergens(Food Allergen Labeling and Consumer Protection Act of 2004(FALCPA)) • Sanitation Standard Operating Procedures • Pest Control Program • Foreign Material Control Policy • Employee Training Program • Recall and Traceability Program We are registered with the FDA under the Bioterrorism Act of 2002 and our registration number is XXX-XXX-47868. Please retain this document as a guarantee to our quality and food safety for the year of 2019. Sincer y, YJ�ohks Operations Manager Azuma Foods International Inc., U.S.A. 20201 Mack Street, Hayward, CA 94545 HACCP COMPLIANCE LETTER January 03,2019 To:Hissho Sushi, In compliance with the U.S.Department of Health and Human Services Food and Drug Administration,21 CFR Parts 100^Parts 123,we provide this letter to certify that Azuma Foods International Inc.,USA has taken appropriate steps, including those outlined below to comply with the FDA's HACCP regulations. The HACCP(Hazard Analysis and Critical Control Points).programs,system and documentation implemented at Azuma Foods International Inc.,USA are based on risk assessment and are in substantial compliance with the principles and guidelines. Biological,physical and chemical hazards have been evaluated for each process.Identified hazards are evaluated for likelihood of occurrence and severity. Significant hazards are controlled by pre-prerequisite programs, preventive controls,or critical control points unless otherwise stated in product specifications. Products provided to Hissho Sushi: 11723 Ajitsuke Inari(Tawara)Gluten Free 50324 Ebi Tempura Bulk(M) 82335 Goma Wakame"Delight" 82543 Calamari Salad"Gluten Free"ECO 82632 Calamari Salad 82649 Masago"Delight"ECO Our HACCP program is monitored and verified regularly. Validation of these programs is conducted by qualified individuals trained by third party consultants using current guidelines. This validation occurs annually or more frequently based on internally defined events. The compliance to these guidelines is audited by third party auditor annually. We guarantee the products that are produced have food safety controls in place to ensure the product provided is in good condition,not adulterated in any manner,and are manufactured in a clean and sanitary environment. • AFI have implemented food safety controls and HACCP program in place • AFI maintain a record keeping system to monitor our products • AN follow Good Manufacturing Practices • AN have HACCP certified personnel • Parasites are controlled by freezing and storing at an ambient temperature of-4°F(-20°C)7 days or longer for all our frozen products • Factory FDA Registration Number#XXXXXXX5990 • NY Distribution Branch FDA Registration Number:XXXXXXX4066 If you have any questions or require assistance,please contact us. Please receive this document a u- om @ der to be included as part of your HACCP file. O �O i{�CORP0, �c yQality re Sat Assurance Manager; 7 JU2;a Foods International I` c. CALIFOR�`P E-mail- general@azumafoods.com Website: www.azumafoods.com BEAVER STREET FISHERIES, INC. D MTM SEAFOOD • MEATS • IMPORTER • EXPORTER • PRODUCER • WHOLESALER (±^QUALITr SINCE 1979 1741 West Beaver Street,Jacksonville,Florida 32209 P0.Box 41430 Jacksonville,Florida 32203-1430 904.354.5661 1800.874.6426 1 Fax:904.633.7271 January 1, 2019 To: Hissho Sushi Re: FDA registration#16372232336 and letter of compliance with HACCP regulations. To whom it may concern: With the HACCP Regulations having become mandatory for all seafood facilities on the date of December 18, 1997, it is important that we notify our customers that Beaver Street Fisheries, Inc., is in full compliance with the federally mandated requirements. In addition as a food producer, importer, and distributor,we have taken the necessary steps to ensure the compliance of both our domestic and international suppliers with all current regulations listed under the Food Safety Modernization Ace (FSMA), and specifically Foreign Supplier Verification Program (FSVP)as it pertains to imported seafood. Our HACCP program is based on the Fish and Fishery Products Hazards and Control Guidance-Fourth Edition of April 2011,Title 21 CFR Part 123—Fish and Fishery Products and Good Manufacturing Practices part 110. In September of 1994,our company applied to the U.S.D.A.for inclusion in the European Union Certificate Program. At that time we began assembling a HACCP team and educating ourselves on the criteria for writing and implementing a HACCP plan. We were accepted into this program in December of 1994. Our fully operational HACCP plan is in place,and is periodically monitored by the U.S.F.D.A. Our company has been contracted with the National Marine Fisheries Service under type 1 inspection service since 1990. The N.M.F.S. inspection and training branches were instrumental in assisting us in developing our HACCP plan. In fact,we have over sixty employees that have received HACCP training through the N.M.F.S.training branch. I trust this letter has answered any questions you may have, however if I can be of further assistance in any way, please feel free to contact me. Item sold d to Hissho Sushi:Cooked Salad Shrimp Sincerely, Nathan A.Spiritas Beaver Street Fisheries, Inc. 1741 West Beaver Street Jacksonville, FL 32209 Black Pearl Seafood, LLC 690 Canton Street, Suite 300 Westwood, MA 02090 Hissho Sushi, Inc. January 1, 2019 11949 Steele Creek Road Charlotte, NC 28273 CERTIFICATE OF COMPLIANCE This document certifies that as of December 18'", 1997; Martin International Corporation/Black Pearl Seafood, LLC has been and currently is operating in full compliance with all Federal mandated HACCP(NOAA certificate#04.0897)regulations under FDA(title 21 of CFR part 123). Martin International Corporation/Black Pearl Seafood, LLC have conducted a hazard analysis for all fishery products and implemented standard operating procedures based upon good manufacturing practices as outlined by the U.S, Food and Drug administration. In addition to HACCP compliance, all salmon products packed under the Black Pearl trademark or distributed by Martin International Corporation/Black Pearl Seafood, LLC are raised in net pens in the open sea; free of antibiotics, free of any antifungal residues, do not contain nitrites and have never received or been administered any banned aquaculture drugs or therapeutic agents.. All farm raised products (including farm raised Salmon, Artic Charr, Halibut,Trout and Cod)are raised solely upon palletized feed that does not contain any fish waste of any kind and all products are free of internal and external parasites and do not contain any banned substances. The processing plant that packs all product we ship to you is registered with the US FDA under number:#13518991074. All frozen processed and packed under the Black Pearl or Sustainable Harvest trademark have been frozen for a minimum of seven (7)days prior to delivery and maintained at a maximum (- 20°C)during storage and transit., Please include this HACCP document as part of your HACCP file. If you have any further questions, please call me at your convenience. ncerel cxn Richard C. Martin Jr. President Phone: 781.375.2125 Fax:781.375.2158. • Mobile:617.966.8707 www.blackpearlse6food.com 04% DNI GROUP January 2, 2019 Prepared For: Hissho Sushi HACCP Guarantee and Parasite Destruction Letter This letter guarantees that the products supplied by DNI Group, LLC comply with the United States Department of Agriculture(USDA),and United States Food and Drug Administration(FDA) Hazard Analysis Critical Control Point(HACCP) regulations.Our records reveal that all DNI Group, LLC products purchased by your company meet our quality specifications,and are free of non-permitted aquaculture drugs,additives and environmental chemicals.This commitment is for a period of twelve months and will be renewed upon expiration. Products: Passport Cuisine®Gyoza are produced under guidance and inspection by USDA,and are frozen to-15°F or colder for at least 45 minutes and stored and distributed at 0°F or below. Crane Bay® Frozen Atlantic Salmon fillets are treated by freezing at an ambient temperature of-31F° (- 35°C)or below until solid and stored at-31F°(-35°C)or below for a minimum of 15 hours.Our Atlantic Salmon is farm-raised and fed by a diet made entirely by extruded pellet. • Item#20004—Passport Cuisine® Premium Vegetable Gyoza is fully cooked • Item#28511—Passport Cuisine® Pork Gyoza is fully cooked • Item#28512—Passport Cuisine®Wakadori Chicken Gyoza is fully cooked • Item#6101—Crane Bay Frozen Atlantic Salmon Fillet,Trim C Premium • Item#6102—Crane Bay Frozen Atlantic Salmon Fillet,Trim E Premium Company: DNI Group, LLC Address: 250 Bel Marin Keys Blvd, Bldg. G, 2nd Floor; Novato,CA 94949 FDA Registration Numbers: 11463761526-Los Angeles,CA 15147280584-Newark, NJ 10423288688-Miami, FL Best regards, Min C o Vice Presiden 2$6BeI'Marin Keys Blvd,,Bldg G,-Ind FloorNavalo CA 94949+ Phone;(4151382,9999!R1'Toll'Free (8881364 4768+' k Fox J41 382=9990 f er i. ItAf-0100$ . Certificate of Compliance Dear Hissho Sushi, This is to certify that the seafood we supply to your company has been produced in a facility that complies with Good Manufacturing Practices, operates under a program of proper Sanitation Standard Operation Procedures, and follows the United States Food and Drug Administration(FDA)guidelines for Hazard Analysis Critical Control Point (HACCP). Specifically, our products are processed in accordance with the requirements of the US Food and Drug Administration Regulation 21 CFR Part 123. We understand that this is a continuing guarantee that we will renew with your company once every twelve months. Executed by Supplier this lst day of January, 2019 valid until December 31St, 2019. Our FDA Bioterrorism Registration number is: 15589635542 Products supplied to Hissho Sushi by Fisher King Seafoods Limited: - Peeled and Cooked Shrimp - Rock Crab Combo Meat Sincerely, Chris Redmond Director, Supply Chain Fisher King Seafoods Limited. i i Al)?Grin" Mc. a22 G.:IltrrttFrglatt l)ttvc, S'utte`212, ArcctClic<; Crl. 9101(: T�lelftvtre °s(G�6f 3�� ��7�: Attri Sydney FI-eaton: Fti sho'Sush;i lj'049 Steele'Cenk R6ad, Charlotte,NC 28273 el:(I04)926-3990 Fax:(704) 92,6-3.991 Date: January 01,2019 Re::Letter of Guarantee This lette` Is.tb lssUre 'ott that al l seafood sold to yotir,eornpfiny front Amerin inc. l as been processed and produced under a fun,(zfl Tina l-lazard'Analysis Crifi,cal .Control,Point (HACCP).Plrin and Sanitafy Standard Opprdi ingPlan.(SS,QP);Using Good Manuf eWting- Practice(GI P). Walso guarantee'thatthe-seafood colhohy does not use sulfites in our :mw' and cooked;shrimps-p.rocesshig. "Corensurer;our product's freshness, please n1ainta.in product frozen at=I W. For cooked S}atin7p'paras.ite destrttc'i6m f'rtizen uiid.stored.at a tei Zperatu.re o'f- 20�C(- °F) Or below fo'r a minimum-of 168 hours.(7 days).in a freezer.- The Product:Amerni Inc. supply to Fl:issho S.uslii are listed in the following: lteri code 204 f 'Sushi Ebi 3L.(cooked shrimp) Item code 20441=L Sushi EW AL.(cooked shrimp) Please keep this letter as,documentation •in case youu need`,to compl3 with HACCP procedures as we11,as a guarantee letter that oiu prodiicts;ate"-sulf to free: Our'FDA Registration number: '1111$349* 04 Please te0I free.to c ontact us ifyou have ai y,furiher,cl tes[iorts.. Sii.cerzly �13ett3a''Ha}=ash i HILO FISH COMPANY, INC. 55 Holomua St. - Hilo,Hawaii 96720 Phone: (808)961-0877 - Fax: (808) 934-8783 coi PAN ANC. Email: hfc@hilofish.com - Internet: www.hilofish.com COMPANYSH INC. HAWAR HAWAH Updated December 31, 2018 Hissho Sushi 11949 Steele Creek Road Charlotte,NC 28273 Valid: January 1, 2019- December 31, 2019 This letter certifies that Hilo Fish Company,Inc. is operating in full compliance with the United States FDA mandated HACCP program illustrated in regulation 21 CRF Part 123 and 1240. Hilo Fish is also in compliance with all Federal and State"Fair Packaging and Labeling Act" Hilo Fish Company,Inc. has conducted a hazard analysis for all products and has implemented the necessary procedures to prevent hazards from occurring. Hilo Fish Company,Inc, has established Standard Sanitation Operating Procedures in accordance with Good Manufacturing Practice in manufacturing,packing or holding human food. Any questions may be directed in writing to Sabrina Vaughn,Corporate HACCP Coordinator,via e- t nilaa@@W or fax at (608 -948783tS a i FDA REGISTRATION NO: 10310363706 PRODUCT LIST: Frozen CO and TS Tuna Saku,Tuna Loins,Tuna Steaks,Tuna Chunks,Tuna Nakaochi,and Tuna Cubes. Frozen CO and TS Snappers Fillets/Portions, Frozen CO and TS Groupers Fillets/Portions, Frozen Escolar,and Frozen Seaweed Salad. B Regards, VV brina Vaughn orporate HACCP Coordinator Hilo Fish Company,Inc, K Z2 I o`S s0 oN' HILO FISH COMPANY, INC. 55 Holomua St. - Hilo,Hawaii 96720 Phone: (808)961-0877 - Fax: (808) 934-8783 �► 4NmO sN c scMyuaI Email: hfc®hilofsh.com Internet: www.hilofsh.com o HAwAU HAwAU Updated:December 31,2018 Hissho Sushi j 11949 Steele Creek Road Charlotte,NC 28273 Valid:January 1,2019—December 31,2019 Freezing 3-402.11 Parasite Destruction (A)Except as specified in'9[(B)of this section,before service or sale in READY-TO-EAT form,raw,rraw-marinated,—partially cooked,,-or marinated-partially cooked�FISH`other than MOLLUSCAN SHELLFISH shall be: (1) Frozen and stored at a temperature of-20°C(-4°F)or below for 168 hours(7 days)in a freezer;or (2) Frozen at-35°C(-31°F)or below until solid and stored at-35°C(-31T)for 15 hours. (B) If the fish are tuna of the species Thunnus alalunga,Thunnus albacares(Yellowfin tuna), Thunnus atlanticus,Thunnus maccoyii(Bluefin tuna,Southern),Thunnus obesus (Bigeye tuna),or Thunnus thynnus(Bluefin tuna,Northern),and Snapper species (Pristipomoides spp.) the FISH may be served or sold in a raw,raw-marinated,or partially cooked READY-TO-EAT form without freezing as specified under I(A)of this section. This information was obtained from the"FDA Food Code-Chapter 3:Food". R1 �, t�aN HILO FISH COMPANY, INC. •- -��> 55 Holomua St. �- Hilo,Hawaii 96720 I ► Phone:(808) 961-0877 -- Fax: (808)934-8783 HoM rNH Email: hfcQhilofish.cam Internet;www.hilofish.com i�nr �nvc. HAWAII HAWAII All frozen tuna and snapper products sold by Hilo Fish Company, Inc. are from the species listed above,which according to FDA can be served or sold without being frozen as to the specification under It (A)mentioned above. Regardless of this our products are either blast frozen,nitrogen frozen or brine frozen (a liquid freezer)where temperatures are ranging from-40°F down to-50°F. Furthermore,our products are harvested and processed in South East Asia from where shipping to the US usually takes 4-5 weeks. Temperature inside the containers used to ship product to the US are set at 0°F or below (DeltaTrak temperature recorders are retrieved from each container to confirm this by a Hilo Fish employee). After.product arrives into the US it will be stored at public cold storages that maintain temperatures of 0°F or below. In regards to the information listed above Hilo Fish's frozen tuna products surpass FDA's Food Code for Parasite Destruction in Fish. FDA REGISTRATION NO:10310363706 PRODUCT LIST: Frozen CO and TS Tuna Saku,Tuna Loins,Tuna Steaks,Tuna Chunks,Tuna Nakaochi,and Tuna Cubes. Frozen CO and TS Snappers Fillets/Portions, S' cereIy, V Sabrina Vaughn Corporate HACCP Coordinator Hilo Fish Company,Inc. .Er s o N* at.io. .9..ao. 0 m January 8,2019 Inland Seafood Hissho Sushi To Whom It May Concern; Inland Fresh Seafood Corporation of America currently supplies Hissho Sushi with the following products: 120430 ULT Tuna Tristan International is our vendor of choice for the ULT Tuna. Tristan International meets the requirements of Code- 511-6-1-.04 Food(5) Pathogen Destruction (d) Parasite Destruction.Sushi or Sashimi grade products have undergone freezing and storing at an ambient temperature of-76°F(-60'C)or below for a minimum of 168 hours (7 days),which is sufficient to kill parasites. Tristan International is HACCP certified. As a part of our Vendor Management Program, Inland Seafood maintains a copy of their current FDA Registration Number,Certificate of Compliance, HACCP Plan,and current Third Party Audits. Our commitment to safety and quality involves our vendors. We are proud to supply you with safe,quality products from Tristan International. Inland Seafood Corporation is registered with the United States Food and Drug Administration under registration number XXXXXXX1178,and is in full compliance with the Bioterrorism Preparedness and Response Act of 2012. Best Regards, Anya L. Ford, Quality Assurance Manager Corporate Office: 1651 Montreal Circle 2700 Avenue D 37'_5 N. Daviclson Street P.O. 13ox 172 2527 Perdido Street Atlanta, GA 30084 liirminaham,AL 3521.$ Charlotte, NC 28205 Mill.briclge, ME 04658 New Orleans, IA 70119 404-350-5850 205-252-0344 704-332-3474 207-546-3333 504-821-4500 HEAD OFFICE .09CIN70WARONAL INC 7101 EAST SLAUSON AVENUE,LOS ANGELES,CA 90040-3622 P.O.BOX 875349 TERMINAL ANNEX,LOS ANGELES,CA 90087-0449 TEL.(323)721-6100 FAX.(323)721-6133 January 1,2019 Hissho Sushi 11949 Steele Creek Rd Charlotte,NC 28273 Dear Hissho Sushi, Frozen seafood products that have had parasite destruction were stored at -l° F or lower, for more than seven consecutive days or were fully cooked at the vendor's processing plant prior to JFC receipt. Item# Description FDA Registration Number 11924 WP UZUSHIO IKA 9-12P WLD THAI 2/12/16 OZ xxxxxxx6276 JFC International Atlanta Branch: FDA Registration number xxxxxxx7252 We further certify that we, and our suppliers, operate in accordance with the United States Food and Drug Administration Regulation,HACCP(Hazard Analysis Critical Control Point),21 CFR Part 123. Parasite destruction seafood products (amongst the purchased items) will be listed on the last page of our sales invoice. If you have any further questions,please call us at 1800-633-1004 Sincerely, 2 Toshiyuki Ogawa General Manager Merchandising Department Marketing Planning Division SAN FRANCISCO • LOS ANGELES• HOUSTON CHICAGO NEW YORK BALTIMORE ATLANTA MIAMI SEATTLE DENVER HAWAII L"Fbads Where Loyalty Matters 100 Raskulinecz Road,Carteret,NJ 07008 January 2nd,2019 To: Hissho Sushi Re: HACCP Letter This letter certifies that LM Foods,LLC, supplier of Hissho Sushi for the following products: • 12006 Natural Sushi Stick 10x1.5# • 12027 Dyna Sea Kosher Stick 12x1# Is operating in full compliance with the United States FDA mandated Hazard Analysis Critical Control Point(HACCP)program illustrated in regulation 21 CFR Part 123.9 LM Foods, LLC has written and implemented Standardized Operating Procedures (SSOP's), conducted a Hazard Analysis of all its.seafood operations, identified its Critical Control Points, and developed an HACCP plan in accordance with FDA guidelines. Our freezing process runs for 90 minutes and temperature of the product is below 20°F. Please file this as part of your HACCP record. LM Foods, LLC. look forward to serving your seafood needs and supplying you with the best HACCP protected seafood available. If you have any questions or need any further information,please feel free to contact me at(732)- 855-9500 or via e-mail at heidi.duverge@aquamar.net FDA FACILITY REGISTRATION NO: 15544074536 01/02/2019 l Heidi Duverge/QA MhQager Tel: 732-855-9500• Fax:732-855-7474 LUCKY UNION FOODS CO.,LTD. 1/74-75SUMUTSAKORN INDUSTRIAL ESTATE,RAMAII ROAD,M002, THASAI,MUANO,SAMUTSAKORN 74000,THAILAND TEL:(6634)490.009.12,490330.4 FAX(6634)4"1 MARKETI NG FAX(")490-013 Website:w rw.suflmipmdwm.o= Date:January 1, 2019 Subject:Certificate of compliance Issue to: Hissho Sushi Address: 11949 Steele Creck Rd.Charlotte, NC 28273 Phone:704.926.2200 We, Lucky Union Foods (USFDA Registration no: 10051631960), hereby certify that surimi products as the table below are fully cooked (Ready to eat). Both products are manufactured by Lucky Union Foods Co., Ltd. and processed under freezing temperature,core temperature at lower than-18 °C for 30 minutes. Furthermore, under the global food safety standard, ISO, HACCP,GMP,we confirm that these products are manufactured and handled in a clean &sanitary manner as to ensure its safety. Item Manufacture code Packing Type Surimi Crab Sticks LU-US-027EFV-9 10 PCK x 2.5 LBS. Vacuum Surimi Crab Shredded LU-US-028EFV-9 10 PCK x 2.5 LBS. Vacuum Valid thru December 31, 2019 Yours Faithfully, (Mr.Chakkawat Chantarasuwan), R&D Manager On behalf of Lucky Union Foods Co.,Ltd. EQA BLUE CORPORATION 1250 OAKMEAD PARKWAY SUITE 210 SUNNYVALE CA 94.085 TEL'.(408)823-2977 EMAIL:MEGABLUECORP@aGMAIL.COM Certificate of COM101hance Date: 01/01/2019 Dear Hissho Sushi, As,''an. .importer of seafood we are required to comply with Title 21 Coda of egulations Part 123 Section 123.12 Special requirements for imported t"vduc;ts; This section. -p, states that we must maintain and implement written verification h.prO .ures:for•enouring'that the fish and fishery products that we offer for import into the 3tat+�siwere'proosssed in accordance with the requirements of Part 123. compliance`•w q rdduc# specifications that were ' ith.this:` re uirement wo have P ,rpiria .ar�d preser�ted:to.our;suppliers to:erisure'that the product we import-from them >. f .'at :,`cc�mpGacice with the mandates of .the .Food .Drug and Cosmetic Act including. °..`p ©c :gsing seafood'.,under the seafood FIACCF' regulation (Title 21 Code of Federal Regulations Pahl 123). >:.In.add'ition.as required by the HACCP regulation we have an affirmative step that . consists*-of' of-obtaining. either a continuing or lot- by-lot certificate•from an appropriate . ... :,+ Sa" ,,,,4.foreign,,government'inspection:aiathbhty_or•,-O'P t nt-tlhi4 party that certifies the fish or fshery:.product we imported is or was processed in accordance with the requirements - :.;:,::,. itI621 Code of Feder al Regulations Fart 123. This letter covers these products supply to Hissho Sushi: Yellowfin tuna lue.dorporation.FDA,Bioterrorism-Re istration number is 17685371206.' �''> y'�``;tr :�;Atl:abrivo'-these products are.tent in.HACCP regulated freezer storage under.-15 degree 5:•.'.•:'i. S 1 .. .. "` a o.,r,d u k a ion t I •ast!2 ars. The valid date of this certific ate letter is on yr' �i., �Fi.{•hQ..... .. .. MING HONG INTERNATIONAL MING HONG 14730 DON JULIAN ROAD,CITY OF INDUSTRY,CA 91746 USA TEL:(626)820-9888 FAx:(626)820-9088 January 1",2019 Hissho Sushi . 11949 Steele Creek Rd Charlotte NC 28273 This letter serves as a continuous guarantee that the frozen Hamachi fillet/loin/collar,frozen Atlantic salmon fillet,frozen steelhead fillet or slice, frozen izumidai,frozen hokki gai(arctic surf clam),frozen roasted eel (unagi)or slice,frozen tuna saku,loin,cube,ground or slice,frozen escolar,frozen anago(conger eel),frozen octopus(madako),frozen squid salad,frozen soft shell crab,frozen smoked salmon,frozen edamame,frozen tamago, sushi ebi,nobashi ebi,spot prawn, frozen masago,frozen tobiko,frozen veg. spring rolls,frozen oyster,frozen marinated mackerel, frozen scallop,frozen albacore tuna,frozen snow crab meat,frozen kanikama,sushi ginger that we carry are produced in a facility that complies with the HACCP Regulation 21 Code of Federal Regulations Parts 123 and 1240."Procedures for the Safe Processing and Importing of Fish and Fishery Products".These regulations require the application of Hazard Analysis and Critical Control Point(HACCP)evaluation principles to the processing of all domestic and imported seafood produced after Dec. 18, 1997.The Principles include: 1. Conducting a hazard analysis of the seafood processing to determine if there is a significant likelihood that a food safety hazard may occur. 2. Writing and implementing a HACCP plan if a significant hazard is identified. 3. Monitoring eight key areas of sanitation regardless of whether a HACCP plan is necessary in order that conditions and practices confirm with Good Manufacturing Practices(GMP). Ming Hong International imports products only from facilities that provide documents to verify their compliance with the aforementioned regulations. It will also source products from U.S. suppliers who can demonstrate that they have taken steps to comply with the HACCP regulations. Further more,we certify that the raw fish in Ready-To-Eat form such as frozen Hamachi fillet/loin/collar,frozen atlantic salmon fillet, frozen steelhead fillet and slice,frozen tuna saku,tuna loin,tuna ground,tuna cube,tuna slice,frozen escolar,frozen cooked octopus,frozen cuttlefish fillet,frozen squid salad,frozen tilapia,frozen smoked salmon,frozen unagi roasted eel,frozen masago,frozen tobiko,frozen half shell oyster,frozen marinated mackerel,frozen scallop,frozen albacore tuna,frozen snow crab meat,frozen sushi ebi,frozen spot prawn, kanikama,mongo ika,supplied to your company are processed in a refrigerated room,where they are filleted,portioned and vacuum packed. After that they are quick frozen at-35 degrees C. (- 31 degrees F.)and they have been maintained at-20 degrees C. (-4 degrees F.)or below in freezer or during transportation at least for 7 days to ensure elimination of parasites. Our FDA registration#is 16470918166 If you have any questions,please don't hesitate to call me at(626) 820-9888. Sincerely yours, I Cyr\h amen Randy Chen General Manager d� Multiexport Foods Nourishing the future TO: Hissho Sushi FROM: Jason Paine DATE: Monday,January 711,2019 SUBJECT: 2019 Certificate of Compliance/Written Verification This letter is to guarantee that the seafood that Multiexport Foods supplies to your company has been handled in the US in compliance with the US FDA HACCP regulations as set forth in 21 CFR 123. This certificate applies to all products provided to Hissho Sushi, including: • Frozen fillets: o Frozen salmon fillet 3-4 lb,Trim E,skin-off, IVP o Frozen salmon fillet 3-4 lb,Trim D,skin-ON, IVP o Frozen salmon fillet 3-4 lb,Trim C,skin-on,IQF • Cold Smoked Products: o Cold,Smoked 2-3 lb,skin-off, unsliced. For all our imported products,we have implemented our verification procedure according to 21 CFR 123.12 to ensure product is not adulterated under section 402 of the Federal Food, Drug and Cosmetic Act.'Our trained personnel are monitoring and recording all activities required, including product specifications, keeping on file a copy of the producers HACCP plan, and a written Certificate of Compliance from our parent company Salmones Multiexport (Atlantic salmon and trout from Chile). We also maintain an annual certificate from the National Fisheries Service of Chile, Sernapesca. These records are kept on file at our facility. Salmones Multiexport,our parent company, is the primary supplier to Multiexport Foods, Inc. of our farm-raised,Atlantic salmon from Chile.Their production facility is registered with the FDA under registration no. 15785317938. Our company understands that this is a continuing guarantee and will be re-issued on a yearly basis. �l-----== to Company Official: Date: January 7 _, 2019 Print: Jason Paine Title: General Manager Company Official: Date.January 71h, 2019 Print:'Juan ceu Titl rations Manager—USA 703 Waterford Way• Suite 510 • Miami, Florida 33126•Phone: (305)364-0009• Fax: (305) 364-0154•www.muttiexportfoods-usa.com Muidexport Foods CL 076-07012019 Puerto Montt, January 07th 2019 QUALITY STATEMENT This statement covers the HISSHO SUSHI products produced in smoked and fresh and frozen processing lines of the factory for species Atlantic Salmon(Salmo salar). The Atlantic Salmon are grown in a land-based hatcheries the first half of their life and grown out in floating cage system for the final stage.The feed of Salmon in every stage is performed with extruded pellet. The products produced in the fresh and frozen processing line are: • Frozen Fillets: - Frozen Salmon Fillet 2-3 Lb,Trim E, Skin-off, IVP - Frozen Salmon Fillet 3-4 Lb,Trim E, Skin-off, IVP Frozen Salmon Fillet 3-4 Lb,Trim D, Skin-On, IVP • Cold Smoked Products - Cold Smoked 2-3 Lb,skin-off, unsliced These products are processing under strict quality norms and according to HACCP regulations 21 CFR part 123 and Good Manufacturing Practices CFR 110. The HACCP plan has considered in your risk evaluation the "Presence of Parasites", this evaluation indicate that Parasites is a control point and defined the preventive measures that are: - Control of raw material for every cage that entering to the process, this control is performs by quality control people that have been trained to detect parasites. The control considered a 5 sample of fillet that is cut and put on the table with light,the light allows identify the presence of parasites. - Monitoring every 15 days in laboratory the finished product is analyzed to identify of different type of parasites through light.This analysis is performed by people has been trained to detect parasites. Avda.Cardonal N°2501—Puerto Montt —Chile.Fono(56 65)2483 880 Fax(56 65)2483 801 www.multiexoortfoods.com ®� Multiexport Foods ®� - Alimentos Multiexport S.A. has applied the freezing method of parasite control.by following the HACCP regulation of Freezing and Storing at—40F(-200C)or below for 7 days(total time)and over The monitoring we do on raw material and finished product and have shown that parasites are not a risk. Note: This document is valid until December 31th$ 2019. Marcella Castillo Aranda Quality Assurance Manager Alimentos Multiexport S.A. Avda.Cardonal N°2501—Puerto Montt —Chile.Fono(56 65)2483 880 Fax(56 65)2483 801 www.multiexportfoods.com i 0 Ocean Blue 668 S.Alameda St. Ste B. Los Angeles, CA 90021 © Products, Inc, Tel: 213-688-0133 Fax: 213-688-0137 CERTIFICATE OF COMPLIANCE Date:January 1, 2019 Hissho Sushi 11949 Steele Creek Road Charlotte, NC 28273 Dear Hissho Sushi, The Food and Drug Administration has developed, with support of United States seafood industry members, HACCP (Hazard Analysis Critical Control Points) regulations that were effective since December 18, 1997. This letter is to notify you that Ocean Blue Products, Inc. is not required to have a HACCP plan of our commercial situation.This situation is as follows: 1. We do not process any fishery products 2. We use only public cold storage facilities for our products 3. We use only public common carriers for the transport of our products We have on file the following as required by the FDA seafood HACCP regulation: 1. HACCP documents from our foreign suppliers 2. Cold Storage operation protocol from our public cold storage If you have any questions, please do not hesitate to call our office. Warmest Regards, Susan Young Operations Manager FDA Registration No: 15608727810 Ocean Blue 668 S. Alameda St. Ste B. Los Angeles, CA 90021 Products, Inc. Tel: 213-688-0133 Fax: 213-688-0137 Parasite Control Certificate Date:January 1, 2019 Hissho Sushi 11949 Steele Creek Road Charlotte, NC 28273 Dear Hissho Sushi, Ocean Blue Products, Inc. is a leader in providing the highest quality products to our customers and as such is constantly assuring that our products meet the requirements of the United States Food and Drug Administrations HACCP and FSMA Guidelines. This letter affirms that all of our sushi products including: cooked octopus(madako tako), BBQ eel, pickled mackerel (shime saba), soft shell crab, cooked seasoned baby octopus salad, seaweed salad (wakame), sushi grade tilapia fillet(izumidai), seasoned capelin roe (masago), flying fish roe (tobiko), soybeans (edamame),yellowtail (hamachi), yellowfin tuna and escolar are frozen for a minimum of 7 days at or below-4°F (-20°C) for parasite control, in accordance with HACCP requirements. This letter confirms that in accordance with FDA requirements, any fish species (including above mentioned) determined to have parasite hazard and distributed by Ocean Blue Products, Inc. are stored at a temperature of-40F (-20°C) or below for a minimum of 7 days (total time), and/or has been fully cooked by the supplier as recommend by HACCP guidelines. If you have any questions, please do not hesitate to call our office. Warmest Regards, Susan Young Operations Manager FDA Registration No: 15608727810 PLATINA SEAFOOD Miami,January 1,2019 Dear Hissho Sushi: The seafood HACCP Regulations of the United States Food&Drug Administration,21 CFR Parts 123 and 1240,became effective on December 18, 1997. Part 123. 12(a)(2)(i)requires that seafood importers have an implement written product specifications to ensure that the product is not adulterated under section 402 of the Federal Food,Drug and cosmetic Act. Each processor and supplier of fresh and frozen salmon,steelhead and cod of Platina Seafood has conducted a hazard analysis to determine whether there are food safety hazards that are reasonably likely to occur.Any potential hazards were controlled by preventive measures specified in a HACCP Plan. The Frozen salmon,cod and steelhead products are processed in accordance with the above guidelines and frozen at-20 degrees Celsius and kept frozen at this temperature since time of processing. The product is kept frozen for a minimum of 7 days(168 hours)at-20 degrees Celsius before shipping to ensure parasite destruction. The product we provide Hissho Sushi is farm raised Frozen Atlantic Salmon from Chile.Color is added through feed (Astaxsanthin). This document certifies that Platina Seafood and its suppliers operate under federally mandated HACCP regulations. Please include this document as our Certificate of Compliance as part of your HACCP file. y Birgitte gelssen Godoe Compliance Manager Platina Seafood Inc. Platina Seafood Inc. Tel(786)431-1404 31 SE 5th Street Suite 214 Miami, FL 33131 Fax(786)431-1554 ryi t � Sea Delight, LLC jCUIDIELI HACCP & Parasite Destruction Certificate of Compliance Hissho Sushi January 1,2019 This document guarantees that facilities that produce product, supplied by Sea Delight,LLC,do so while operating under and implementing f' - verification procedures as outlined by the federally mandated HACCP (Hazard Analysis Critical Control Point)program and that we have t w - reviewed the current HACCP Plans as set forth in 21 CFR 123. Furthermore, we guarantee that all aspects of GMP (Good Manufacturing Practices) are being followed and we are monitoring and recording applicable sanitation activities in the Standard Sanitary Operating Procedures (SSOP) as set forth in 21 CFR Part 110. All frozen products sold by Sea Delight, LLC are either blast-frozen, e , nitrogen frozen or brine frozen(a liquid freezing agent) at-35°C (-31°F) or -»-- ,' below until solid and stored at-20°C (-4°F)or below for a minimum of 24 hours. Furthermore,our products are harvested and processed in South .' East Asia or South America from where shipping to the US usually takes 2 or more weeks. Temperature inside shipping containers are set at 0°F or below(time,temperature recorders are used in containers to confirm compliance during voyage). After the product arrives in the US it will be f . . stored at public cold storages which maintain temperatures of 0°F or below. • T Items: Tuna Saku CO AAA 12 16oz 1/10# } Tuna Loins CO AAA 3/5# 1%30# Ground Tuna Meat CO 15/1# • '' Sea Delight, LLC is also registered with the U.S. Food and Drug Administration under Title III of the Bio-terrorism and Response Act of 2002. Our FDA registration number is 12023808366. F; Please keep this letter on file as the documentation you need to comply t . , ` with HACCP and FDA requirements. If you have any questions,please do not hesitate to contact us. This certificate is valid through December 31, 2019. Sincere , Randy Brown Director of Quality Assurance 8195 NW 6r Street,Miami,Florida 33166 1 305.594.9797 1 Toll-free 1.888.FISH.199 ( info@sea-delight.com . www.sea-dellght.com '��- -� °n�ol v�ccanr�oncalaDo�vo��n�Q���fl� January 8, 2019 Hissho Sushi Purchasing Coordinator 11949 Steele Creek Road, Charlotte,NC 28273 Re: Letter of Assurance of HACCP Compliance 2019 Dear Quality Assurance Manager, This letter is to certify that frozen fish products that Seafood Imports, Inc. supplies to your company have been produced, imported and stored in a facility which is in compliance with USFDA guidelines for Seafood Hazard Analysis Critical Control Points (HACCP)Reg. 21 CFR Part 123 and Good Manufacturing Procedures (GMP). The Principles include: 1. Conducting a hazard analysis of the seafood processing to determine if there is significant likelihood that a food safety hazard may occur. 2. Writing and implementing a HACCP plan if a significant hazard is identified. 3. Monitoring eight key areas of sanitation regardless of whether a HACCP plan is necessary in order that conditions and practices conform to Good Manufacturing Practices(GMP). Seafood Imports' frozen fish products are: ➢ JAVA@ Brand, Frozen Tuna 3/51bs Loins -Thunnus Species Please keep this letter on file as the documentation you need to comply with HACCP procedures. This Certificate of Compliance will be renewed every 12 months, as HACCP is an ongoing program. Please free to contact us if you have any questions. Sincerely, Seafood Imports, Inc. US FDA REG.# 11950585096 Seafood Imports,Inc.•10505 Sorrento Valley Road•San Diego,CA92121 •P:201266-0531•F:646-434-1379•info Cseafoodimports.com January 8, 2019 Hissho Sushi I Purchasing Coordinator 11949 Steele Creek Road, Charlotte, NC 28273 Re: Parasite Destruction Freezing Method 2019 Dear Quality Assurance Manager, This letter is to certify that Frozen Fish products that Seafood Imports, Inc. supplies to your company have been frozen prior to shipping according to the time and temperature parameters given by FDA as follow: Freezing and storing at-4'F(-20'C) or below for 7 days (total time), or Freezing at -31°F (-35'C) or below until solid and storing at-31°F(-35'C) or below for 15 hours, or Freezing at-31°F(-35'C) or below until solid and storing at-4'F(-20'C) or below for 24 hours is sufficient to kill the naturally occurring parasites in fish. Seafood Imports' frozen fish products are: JAVA@ Brand, Frozen Tuna 3/5 lbs Loins -Thunnus Species Above products are frozen immediately after processing to a temperature of -31°F (-35°C) or below and then stored at-4°F (-20°C) or below for at least 45 days before being put into distribution. Please free to contact us if you have any questions. Sincerely, Seafood Imports, Inc. Seafood Imports,Inc.•10505 Sorrento Valley Road•San Diego,CA92121 •P:201-266-0531•F:646-434-1379-info@seafoodimports.com �.l►illllllll� j Shining0cean, Inc. Trusted Since 1985 CERTIFICATE OF COMPLIANCE & PARASITE DESTRUCTION LETTER FOR HISSHO SUSHI Shining Ocean Inc. hereby guarantees that the surimi-based products purchased from us by Hissho Sushi are fully heat pasteurized in the package for a minimum of 10 minutes at 90 C. This pasteurization process is designed to eliminate all vegetative food pathogens including E Coli, Staph Aureus, Listeria Monocytogenes, Salmonella, and Clostridium Botulinum Type E and non-proteolytic types B and F,and excluding Clostridium Botulinum Type A and Proteolytic Types B and F; hence the need to hold the unopened chilled product packages under refrigeration.This pasteurization process is effective inproducing safe products as long as the temperature of the product in unopened vacuum packages is maintained throughout distribution, and until the package is opened,at 0 F(-17.8 C)or below. Products are frozen at a temperature of-4°C for>ten minutes.These processes are consistent with those recommended by the NFPA in their letter to all surimi analog producers dated, August 3, 2001 and those listed in the FDA Fish and Fishery Products Hazard and Control Guidance, 41h Edition. Shining Ocean, Inc. maintains all HACCP records for a minimum of3 years perpolicy requirements. Shining Ocean supplies Hissho Sushi with the following products: NQ27-T2-MSC Natural Skinny 7" 14/2 Lb. Furthermore,this process reduces overall bacteria counts significantly.The figures that follow referenced counts commonly found in the product on the next day after thaw: Aerobic Plate Count < 500 cfu/g Coliform <20 cfu/g Our pasteurization processes have been reviewed and verified by PhF Specialists,an FDA recognized Process Authority. Shining Ocean's FDA-registration number is: 10594024808 This statement is valid through: December 3 1"2019 By: L�l If Jimmy Wilson Quality Assurance Supervisor Shining Ocean, Inc. 1515 Puyallup Street,Sumner,WA 98390 Phone:(253)826-3700( Fax:(253)891-2148 1 www,kanimi.com VFr 2 r W I C AP INTERNATIONAL SEAFOOD EXPORTERS 64 Airport Road, St. John's, Newfoundland and Labrador, Canada A1A 4Y3 Tel.: (709)739-6368 Fax: (709)739-6620 Hissho Sushi 11949 Steele Creek Rd, Charlotte NC 28273 January 1, 2019 Please be advised that fully cooked and peeled shrimp supplied to your company by Whitecap International Seafood Exporters are processed in facilities that operate under approved HACCP plans. These HACCP plans are compliant with the USFDA HACCP Regulations (21 CFR part 123 and part 110) and Canadian Food Inspection Regulations. As a part of our ongoing commitment to supply safe, top quality products to our customers, we only source product from suppliers operating under approved HACCP programs. In Canada, all processing facilities that supply Whitecap International Seafood Exporters have Implemented Quality Management Programs that include HACCP, and these programs are approved and audited by the Canadian Food Inspection Agency. This product is cooked to an internal temperature of 70°C for 2 minutes or equivalent to achieve a 6 log reduction and frozen to -18°C post cook and peel. Whitecap Seafoods FDA #: 10632930284 Products Supplied: cooked and peeled shrimp Frozen at-35°C (-31°F) or below until solid and stored at-20°C (-4°F) or below for a minimum of 24 hours. Regards, Brian Cuff Director, Quality and Technical Services HISSHO SUSHI 3900 Falmouth Ind. M. Mills SMEA E±.DJ KEEPING YOU ORGANIZED No. 12134 2-163LGN1 WMVE awe ro° POST-CONS mw OX VIUSR W ORGANM AT SMEOMM i g A & K ENGINEERING, INC. Phone: 401-944-6947 78 Amanda Street Fax: 401-944-4332 Cranston, RI 02920 LETTER OF TRANSMITTAL To: Board of Health Date: 03/14/11 367 Main Street Hyannis, MA. 02601 Job No.: SS-066 Re: - - °Stop&Shop Store 066: Cotuit Landing at Marstons Mills Wastewater Treatment Plant Permit No.SE 0-728 Route 28, Barnstable, MA. We Enclose Monthly Operating Report: Month: February Year: 2011 Copies Date Number Description 3/9/2011 GW Monitoring Well Data Report Monthly 3/9/2011 DMR Monthly 3/9/2011 Daily Loq Sheet These are transmitted as checked: - ❑For your approval ❑For your Use x❑ As Required For Review& Comment. .. Remarks: Sent By: Omesh Kumar, PE Copy To: Stop&Shop-Robert T. Hawes Stop&Shop-Michelle Guilbault Tom Cambareri-Cape Cod Planning Commission i Massachusetts Department of Environmental Protection 728 Bureau of Resource Protection - Groundwater Discharge Program 1.Permit Number Groundwater Permit r 2•Tax identification Number I- 2011 FEB DAILY DAILY LOG SHEET 3.Sampling Month&Frequency A. Facility Information Important: When filling out 1. Facility name, address: forms the computer, r,use COTUIT LANDING SHOP CTR only the tab key a.Name to move your 3860 FALMOUTH ROAD cursor-do not use the return b. treet Address key. BARNSTABLE MA --� -- C.City d.State e.Zip Code 2. Contact information: aff ROBERT HAWES ---- = a.Name of Facility Contact Person 6177706212 robert.hawes@stopandshop.com b.Telephone Number c.e-mail address 3. Sampling information: 2/28/2011 ANALYTICAL BALANCE CORPORATION a.Date Sampled mm/dd/ b.Laboratory Name ANALYTICAL BALANCE CORPORATION c.Analysis Performed By(Name) B. Form Selection 1. Please select Form Type and Sampling Month & Frequency jDaily Log Sheet - 2011 Feb Dail ❑ All forms for submittal have been completed. 2 ❑ This is the last selection. 3 Delete the selected form. gdpols 2003-08-13.doc•rev.08/13/03 Groundwater Permit Daily Log Sheet•Page 1 of 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Groundwater Discharge Program 1.Permit Number Ll Groundwater Permit 2 Tax identification Number M£ 2Q9fiEBDQ►1lf DAILY LOG SHEET 3.Sampling Month&Frequency C. Daily Readings/Analysis Information Date Effluent Reuse Irrigation Turbidity Influent Effluent Chlorine uV Flow Flow Flow pH pH Residual Intensity GPD GPD GPD (mg/1) N 1 20945 7.5 7.9 2 3530 7 7.9 3 10406 6.8 8 4 2348 6.3 8 5 4231 6.7 7.9 6 1504 10.8 7.8 7 1504 10.8 7.8 8 7902 10.5 7.9 9 2847 11.6 8 10 3880 10 7.9 11 3410 9.9 8 12 969 10.8 8 13 969 11.2 8 14 969 10.1 7.9 15 4995 9.3 7.9 16 3815 8.3 7.8 17 289 8.6 18 8.4 7.7 19 7 7.8 20 7 7.8 gdpols.doc• rev.08/13/03 Groundwater Permit Daily Log Sheet• Page2 of 3 Massachusetts Department of Environmental Protection 728 Bureau of Resource Protection - Groundwater Discharge Program 1.Permit Number Groundwater Permit 2.Tax identification Number DAILY LOG SHEET 3.Sampling Month&Frequency C. Daily Readings/Analysis Information (cont.) Date Effluent Reuse Irrigation Turbidity Influent Effluent Chlorine UV Flow Flow Flow pH pH Residual Intensity GPD GPD GPD (mg/1) N 21 6.8 7.8 22 3260 7.1 •8.2 23 6031 9.1 8.1 24 6031 8.6 8.2 25 4040 7.5 8.1 26 4854 7.4 8.1 27 6702 12.9 8.1 28 6702 9.8 8.1 29 30 31 gdpols.doc• rev.08/13/03 Groundwater Permit Daily Log Sheet• Page3 of 3 Massachusetts Department of Environmental Protection 1728 Bureau of Resource Protection - Groundwater Discharge Program 1.Permit Number 2.Tax identification Number Groundwater PermitL�111' 1 2011 FEB MONTHLY MONITORING WELL DATA REPORT 3.Sampling Month&Frequency A. Facility Information Important: When filling out 1. Facility name, address: forms on the computer,use COTUIT LANDING SHOP CTR only the tab key a.Name to move your 3860 FALMOUTH ROAD cursor-do not use the return street ress _ key. 1BARNSTABLE MA —- C.City d.State e.Zip Code 2. Contact information: ROBERT HAWES -_- a.Name of Facility Contact Person 6177706212 robert.hawes@stopandshop.com b.Telephone Number c.e-mail address 3. Sampling information: 2/16/2011 RI ANALYTICAL LABORATORIES a.Date Sampled mm/dd/ b.Laboratory Name RI ANALYTICAL LABORATORIES c.Analysis Performed By(Name) B. Form Selection 1. Please select Form Type and Sampling Month&Frequency IMonitoring Well Data Report - 2011 Feb Monthly ❑ All forms for submittal have been completed. 2 ❑ This is the last selection. 3 ❑ Delete the selected form. gdpols 2003-08-13.doc•rev.08/13/03 Groundwater Permit Daily Log Sheet•Page 1 of 1 Massachusetts Department of Environmental Protectionrw� � Mr Bureau of Resource Protection - Groundwater Discharge Program 1.Permit Number r Groundwater Permit 2.Tax identification Number ��' 20 1'FEB�MONTHLY MONITORING WELL DATA REPORT 3.Sampling Month&Frequency C. Contaminant Analysis Information • For"0",below detection limit,or not detected,enter"ND". • For greater than(>)or less than(<)value,enter number only and note greater than(>)or less than(<)in the Comments section. • TNTC=too numerous to count. • NS=Not Sampled. • DRY=Not enough water in well to sample. 1. Parameter/Contaminant 1 2 3 4 Units 2.Well# 3.Well# 4.Well# 5.Well# 6. Well# 7.Well# PH 6.23 6.44 5.61 5.42 S.U. STATIC WATER LEVEL 33.42 38.25 37.66 41.12 FEET SPECIFIC CONDUCTANCE 101 126 .241 134 UMHOSIC , mwdgwp-blank.doc•rev. 10/16/03 Monitoring Well Data for Groundwater Permit Massachusetts Department of Environmental Protection 1728 Bureau of Resource Protection - Groundwater Discharge Program 1. Permit Number j Groundwater Pe 1 �'` 2.Tax identification Number 2011 FEB MONTHLY DISCHARGE MONITORING REPORT 3.Sampling Month&Frequency A. Facility Information Important: When filling out 1. Facility name, address: forms on the computer,use COTUIT LANDING SHOP CTR only the tab key a.Name to move your 3860 FALMOUTH ROAD cursor-do not use the return b.Street Address key. BARNSTABLE MA - - C.City d.State e.Zip Code 2. Contact information: ROBERT HAWES a.Name of Facility Contact Person 6177706212 robert.hawes@stopandshop.com b.Telephone Number c.e-mail address 3. Sampling information: 2/28/2011 ANALYTICAL BALANCE CORPORATION a.Date Sampled mm/dd/ b.Laboratory Name ANALYTICAL BALANCE CORPORATION c.Analysis Performed By(Name) B. Form Selection 1. Please select Form Type and Sampling Month&Frequency Dischar a Monitoring Report - 2011 Feb Monthly All forms for submittal have been completed. 2 FIThis is the last selection. 3 .Delete the selected form. gdpols 2003-08-13.doc•rev.08/13/03 Groundwater Permit Daily Log Sheet•Page 1 of 1 LlMassachusetts Department of Environmental Protection ?$ Bureau of Rescurce Protection - Groundwater Discharge Program 1.Permit Number Groundwater Permit 2 Tax identification Number �2�O��F�,EBM��NTHL�Y DISCHARGE MONITORING REPORT 3.Sampling Month&Frequency D. Contaminant Analysis Information • For"0",below detection limit,or not detected,enter"ND" • For greater than(>)or less than(<)value,enter number only and note greater than(>)or less than(<)in the Comments section. • TNTC=too numerous to count. • NS=Not Sampled 1. Parameter/Contaminant 2. Influent 3. Effluent 4. Effluent Method Units Detection Limit BOD 350 15 3 MG/L TSS 150 ND 2.0 MG/L TOTAL SOLIDS 1100 850 10 MG/L AMMONIA-N 71 10.21 .10 MG/L NITRATE-N 12.5 .5 MG/L NITRITE-N 3.66 .10 MG/L TOTAL KJELDAHw NITROGEN 12.84 .50 MG/L TOTAL NITROGEN(NO3+NO2+TKN) 29.23 .5 MG/L OIL&GREASE 2.4 .5 MG/L CHLORIDE 320 .50 MG/L f infeffrp-blank.doc•rev. 10/16/03 Groundwater Permit Discharge Monitoring Report L71Massachusetts Department of Environmental Protection 1728 —� Bureau of Resource Protection - Groundwater Discharge Program 1.Permit Number k Groundwater Permit 2.Tax identification Number Facility Information Important: ICOTUIT LANDING SHOP CTR When filling out a.Name forms on the computer,use 13860 FALMOUTH ROAD only the tab key b.Street Address to move your 1BARNSTABLE MA r--� cursor-do re turn not use the ret C.City d.State e.Zip Code key. Certification "I certify under penalty of law that this document and all attachments were prepared under my �—� direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who Any person manage the system,or those persons directly responsible for gathering the information, the information signing a submitted is, to the best of my knowledge and belief,true, accurate and complete. I am aware that there document are significant penalties for submitting false information, including the possibility of fine and imprisonment under for knowing violations." or(2)2)or 5.14(1) shall make the following certification Alexander P.Moles 3/9/2011 a.Signature b.Date(mm/dd/yyyy) Reporting Package Comments If you are filing FACILITY FULLY OPERATIONAL PROCESS MEMBRANES REMOVED AND REPLACED. ALL PROCESS electronic-ally and want to TANKS CLEANED AND INSPECTED AERATION DIAPHRAGMS REPLACED AS NEEDED.AIR LINE attach LEAKS REPAIRED PROCESS PUMPS REPLACED PROCESS LIQUIDS AND SOLIDS TRANSFERRED additional BIOLOGICAL PROCESS RESTARTED. SOME OF THE ANALYTES'RESULTS AVERAGED FOR THE comments, MONTHLY REPORT select the check box. El GW_CERT 2003-09-16.doc•rev.08/13/03 Groundwater Permit •Page 1 of 1 MOLES ENVIRONMENTAL SERVICES, INC WASTEWATER TREATMENT PLANT OPERATION REPORT PERMIT: 0728 TAUNTON, MA OPERATOR: B. MOLES COTUIT STOP & SHOP MONTH: FEBRUARY 2011 ------ ----- -------- ----------------- -------- ------ ------ ------ ----- ----- ------ ------- -------------- -------- -------- -------- --------- WEATHER WASTEWATER DISSOLVED CHEMICAL TREATED INF EFF OXYGEN NUTIENTS FINAL FINAL ADDITION DATE TEMP TYPE FLOW MAX DAILY INFLUENT EFFLUENT NOTES F/C gpd gpm pH pH INF EFF NH3 NO3 NH3 NO3 ALK COOH BI-CARB mg/L mg/L mg/L mg/L mg/L mg/L mg/L gal gal ------ ----- -------- --- ------------ -------- ------ ------ ------ ----- ----- ------ ------- ------ -------- -------- -------- -------- --------- 1 45 SNOW 20945 7.5 7.9 <2.5 <2.5 12.7 Transfer Pump Setup 2 35 RAIN 3530 7 7.9 12.7 Heavy Rain,Gate valve setup 3 25 CLEAR 10406 6.8 8 <2.5 5 12.7 Pumpdown LS & EQ, Batch 4 20 CLEAR 2348 6.3 8 <2.5 5 12.7 Pumpdodwn EQ 5 20 CLOUDY 4231 6.7 7.9 12.7 System Off-line 6 1504 10.8 7.8 12.7 7 35 CLEAR 1504 10.8 7.8 12.7 Aeration Repairs 8 30 CLOUDY 7902 10.5 7.9 <2.5 <5 12.7 #2 Aeration Repairs Started 9 20 CLEAR 2847 11.6 8 12.7 Anoxic Tank Repairs 10 20 CLEAR 3880 10 7.9 5 5 12.7 11 10 CLEAR 3410 9.9 8 12.7 2500 gals pumped 12 969 10.8 8 12.7 13 969 11.2 8 12.7 14 45 CLEAR 969 10.1 7.9 12.7 Aeeration #1 Repairs 15 25 CLEAR 4995 G 9.3 7.9 5 7.5 11.8 Found air leak #1 16 25 CLEAR 3815 y 8.3 7.8 11.8 SAMPLES 17 40 CLEAR 289 8.6 7.7 71 15 17 11.8 LS Alarm, Tangled floats 18 0 8.4 7.8 11.8 19 0 7 7.8 11.8 20 0 7 7.8 11.8 21 25 SNOW 0 6.8 7.8 11.8 System returned to Auto 22 15 CLEAR 3260 7.1 8.2 15 7.5 13.6 Increase Sugar 1660ml/cycle 23 20 CLEAR 6031 9.1 8.1 13.6 24 20 CLEAR 6031 8.6 8.2 25 <2.5 13.6 25 40 RAIN 4040 7.5 8.1 10 5 13.6 26 4854 7.4 8.1 13.6 27 6702 12.9 8.1 13.6 28 35 RAIN 6702 9.8 8.1 5.42 8 13.6 Repeat Sampling ------ ----- -------- -------------------------- ------ ------ ------ ----- ----- ------ ------- ------ -------- -------- -------- -------- --------- MIN. 10 0 6.3 7.7 71.0 5.0 5.0 11.8 0 AVE. 28 4005 8.9 7.9 71.0 11.5 7.5 12.7 MAX. 45 20945 12.9 8.2 71.0 25.0 17.0 13.6 0 TOTAL 112132 355.3 0.0 SIGNATURE: MOLES ENVIRONMENTAL SERVICES, INC WASTEWATER TREATMENT PLANT OPERATION REPORT PERMIT: 0-728 TAUNTON, MA TREATMENT PROCESSES OPERATOR: B. MOLES COTUIT STOP & SHOP MONTH: FEBRUARY 2011 ------ ------- --------- -------- ------------------- ------- ----- ------ ----- ----- ----- ----- ------ ----- ----------- ----------- WASTEWATER FILTRATE PUMPS PROCESS PUMP RUN TIMES STOP & SHOP BROOKS TREATED RETURN FLOW DATE FLOW MAX DAILY RATIO RUN TIME METER READINGS WATER WATER gpd gpm #1 #2 TO FP1 FP2 LS1 LS2 TP1 TP2 DP1 DP2 METER METER METER READING gpd INFL Q hrs hrs hrs hrs hrs hrs hrs hrs gallons gallons 1 20945 2361203 2069304 43872 2.09 8 8 1 1 0 1 0 0 2 3530 2363377 2071758 4628 1.31 9 9 2 1 1 1 0 0 3 10406 2370078 2078652 13595 1.31 13 15 5 2 3 2 0 0 4 2348 2372002 2080027 3299 1.41 14 16 5 2 3 2 0 0 5 4231 2374812 2083243 6026 1.42' 16 19 6 3 4 3 0 0 6 1504 B 2327 1.55 7 1504 21377558 2085150 2327 1.55 18 20 8 4 4 3 0 0 8 7902 2'383390 2090261 10943 1.38 22 24 8 4 5 4 0 0 9 2847 2385980 2091964 4293 1.51 23 25 9 5 6 5 0 0 10 3880 2388808 2094220 5084 1.31 25 27 9 5 6 5 0 0 11 3410 2391590 2096373 4935 1.45 27 29 10 5 7 6 0 0 12 969 1316 1.36 13 969 1316 1.36 14 969 2393866 2098046 1316 1.36 28 30 12 7 7 6 0 0 15 4995 2397576 2101228 6892 1.38 31 32 13 7 8 1 1 0 16 3815 2400227 2103954 5377 1.41 32 35 14 7 9 8 1 0 17 289 2400637 2103954 410 1.42 33 35 14 8 9 8 1 0 18 0 0 19 0 0 20 0 0 21 0 2400637 2103954 0 33 35 18 10 11 12 1 0 22 3260 2403787 2105640 4836 1.48 35 36 19 10 12 13 1 0 23 6031 2407610 2110298 8481 1.41 37 39 19 11 13 15 1 0 24 6031 2410245 2113121 5458 0.90 39 42 20 12 13 16 1 0 25 4040 2413752 2116642 7028 1.74 41 44 21 12 14 17 1 1 26 4854 8979 1.34 27 6702 8979 1.34 28 6702 2427422 2129908 8979 1.34 49 54. 23 16 16 23 1 1 NO ACCESS NO ACCESS ------ ----------------- -------- ----------------------------------------------------------------------------------------- ----------- MIN. 0 0 0.90 AVE. 4005 6096 1.42 MAX. 20945 43872 2.09 TOTAL 112132 66219 60604 49 54 23 16 16 23 1 1 NO ACCESS NO ACCESS SIGNATURE: PROCESS ACTIVITIES NOTES: FEBRUARY 2011 DATE: 1-Feb Major Equipment Inspection Feb 1-15th, 2011 Operated in "Batch Mode". Manual Ooperation Anoxic Tank Repaired BOTH Aeration Tanks Repaired EQ Tank and Pumps Inspected 17-Feb High Level Lift Station - Tangled Floats 21-Feb System returned to Auto. 22-Feb Sugar dosage increased 8-Feb Repeat Sampling effluent • eDEP - 1dlassDEP's OnlineFiling System Page 1 of 2 MassDEP Home i Contact i Feedback i Tour I Privacy Policy MassDEP's Online Filing System Usemame:APMOLES Nickname:MESINC My eDEP 1 Forms cO My Profile iciO Help Receipt Forms Signature Receipt Summary/Receipt print receipty Exit Your submission is complete. Thank you for using DEP's online reporting"system. You can select "My eDEP" to see a list of your transactions. DEP Transaction ID: 371113 Date and Time Submitted: 3/9/2011 3:25:56 PM Other Email : DEP Transaction ID: 371113 Date and Time Submitted: 3/9/2011 3:25:56 PM Other Email : DEP Transaction ID: 371113 Date and Time Submitted: 3/9/2011 3:25:56 PM Other Email DEP Transaction ID: 371113 Date and Time Submitted: 3/9/2011 3:25:56 PM Other Email : Form Name: Groundwater Discharge Monitoring Report Forms Facility Information: Tax Identification Number: 043061447 location: 3860 FALMOUTH ROAD Address: BARNSTABLE ZIP Form Name: Groundwater Discharge Monitoring Report Forms Facility Information: Tax Identification Number: 043061447 location: 3860 FALMOUTH ROAD Address: BARNSTABLE ZIP https:Hedep.dep.mass.gov/Pages/PrintReceipt.aspx 3/9/2011 eDEP --MassDEP's OnlineFiling System Page 2 of 2 Form Name: Groundwater Discharge Monitoring Report Forms Facility Information: Tax Identification Number: 043061447 location: 3860 FALMOUTH ROAD Address: BARNSTABLE ZIP Discharge Monitoring Report(1 - 2011 Feb Monthly) Daily Log Sheet(2011 FEB DAILY) Monitoring Well Data Report(1 - 2011 Feb Monthly) Form Name: Comments My eDEP MassDEP Home I Contact Feedback Tour Privacy Policy MassDEP's Online Filing System ver.10.1.4.0©2010 MassDEP https:Hedep.dep.mass.gov/Pages/PrintReceipt.aspx 3/9/2011 �, S YIn A X�4% MAl ©s c �-cD S4G Massachusetts Department of Environmental Protection Provided by MassDEP: Bureau Of Resource Protection - Wetlands Document Transaction Number MassDEP File Number WPA Form 3 — Notice of Intent Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Barnstable City/Town When filling out Important: A. General Information forms on the computer,use 1. Project Location (Note: electronic filers will click on button to locate project site): only the tab key to move your Old Post Road Cotuit, MA 02635 cursor- a.Street b.City/Town c.Zi use the return not Stt Address Y P Code key. Latitude and Longitude: d. Latitude e.Longitude v kA 054 (Municipal Roadway) 030 f.Assessors Map/Plat Number g.Parcel/Lot Number 2. Applicant: Roger Parsons a.First Name b.Last Name Note: Town of Barnstable- Dept. of Public Works Before c.Organization completing this.form consult 382 Falmouth Road your local d.Street Address Conservation Hyannis MA 02601 Commission e.City/Town f.State g.Zip Code regarding any municipal bylaw 508-790-6302 508-790-6406 roger.parsons@town.barnstable.ma.us or ordinance. h.Phone Number i. Fax Number j.Email Address 3.- Property owner(required if different from applicant): ® Check if more than one owner a.First Name b.Last Name Town of Barnstable c.Organization 367 Main Street d.Street Address Hyannis MA 02601 e.City/Town f.State g.Zip Code (508) 862-4000 h. Phone Number i. Fax Number j.Email address 4. Representative (if any): Roger Parsons a. First Name b.Last Name c.Company d.Street Address e.City/Town f.State g.Zip Code h.Phone Number i. Fax Number j.Email address 5. Total WPA Fee Paid (from N01 Wetland Fee Transmittal Form): (municipal fee exempt) a.Total Fee Paid b.State Fee Paid c.City/Town Fee Paid wpaform3.doc•rev. 1/3/2013 Page 1 of 8 Massachusetts Department of Environmental Protection Provided by MassDEP: Bureau of Resource Protection - Wetlands MassbEP File Number WPA Form 3 — Notice of Intent Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Document Transaction NumberBarnstable City/Town A. General Information (continued) 6. General Project Description: Existing municipal roadway surface, drainage and safety improvements. 7a. Project Type Checklist: 1. ❑ Single Family Home 2. ❑ Residential Subdivision 3. ❑ Limited Project Driveway Crossing 4. ❑ Commercial/Industrial 5. ❑ Dock/Pie- 6. ❑ Utilities 7. ❑ Coastal Engineering Structure 8. ❑ Agriculture (e.g., cranberries, forestry) 9. Z Transportation 10. ❑ Other 7b. Is any portion of the proposed activity eligible to be treated as a limited project subject to 310 CMR 10.24 (coastal) or 310 CMR 10.53 (inland)? 1. Z Yes ❑ No If yes, describe which limited project applies to this project: 310 CMR 10.53(3)(f) 2. Limited Project 8. Property recorded at the Registry of Deeds for: NA (municipal roacway) a.County b.Certificate#(if registered land) c.Book d.Page Number B. Buffer Zone & Resource Area Impacts (temporary & permanent) 1. Z Buffer Zone On'y—Check if the project is located only in the Buffer Zone of a Bordering Vegetated Wetland, Inland Bank, or Coastal Resource Area. 2. ❑ Inland Resource Areas (see 310 CMR 10.54-10.58; if not applicable, go to Section B.3, Coastal Resource Areas). Check all that apply below. Attach narrative and any supporting documentation describing how the project will meet all performance standards for each of the resource areas altered, including standards requiring consideration of alternative project design or location. For all projects affecting other Resource Area Size of Proposed Alteration Proposed Replacement(if any) Resource Areas, please attach a a. ❑ Bank narrative 1. linear feet 2. linear feet explaining how b. ❑ Bordering Vegetated the resource area was Wetland 1.square feet 2.square feet delineated. c. ❑ Land Under 1.square feet 2.square feet Waterbodies and Waterways 3.cubic yards dredged wpaform3.doc•rev. 1/3/2013 Page 2 of 8 Massachusetts Department of Environmental Protection Provided by MassDEP: Bureau of Resource Protection -Wetlands MassDEP File Number WPA Form 3 — Notice of Intent Document Transaction Number ILI Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Barnstable City/Town B. Buffer Zone & Resource Area Impacts (temporary & permanent) (cont'd) Resource Area Size of Proposed Alteration Proposed Replacement(if any) d. ❑ Bordering Land Subject to Flooding 1.square feet 2.square feet 3.cubic feet of flood storage lost 4.cubic feet replaced e. ❑ Isolated Land Subject to Flooding 1.square feet 2.cubic feet of flood storage lost 3.cubic feet replaced Little River f. ® Riverfront Area 1. Name of Waterway(if available) 2.Width of Riverfront Area (check one): ❑ 25 ft. - Designated Densely Developed Areas only ❑ 100 ft. - New agricultural projects only ® 200 ft. -All other projects 3. Total area of Riverfront Area on the site of the proposed project: 0 square feet 4. Proposed alteration of the Riverfront Area: 0 a.total square feet b.square feet within 100 ft. c.square feet between 100 ft.and 200 ft. 5. Has an alternatives analysis been done and is it attached to this NOI? ❑ Yes® No 6.Was the lot where the activity is proposed created prior to August 1, 1996? ® Yes❑ No 3. ❑ Coastal Resource Areas: (See 310 CMR 10.25-10.35) Check all that apply below. Attach narrative and supporting documentation describing how the project will meet all performance standards for each of the resource areas altered, including standards requiring consideration of alternative project design or location. Online Users: Include your Resource Area Size of Proposed Alteration Proposed Replacement(if any) document transaction a. ❑ Designated Port Areas Indicate size under Land Under the Ocean, below number (provided on your receipt b. ❑ Land Under the Ocean page)with all 1.square feet supplementary information you 2.cubic yards dredged submit to the Department. c. ❑ Barrier Beach Indicate size under Coastal Beaches and/or Coastal Dunes below d. ❑ Coastal Beaches 1.square feet 2.cubic yards beach nourishment e. ❑ Coastal Dunes 1.square feet 2.cubic yards dune nourishment wpaform3.doc•rev. 1/3/2013 Page 3 of 8 Massachusetts Department of Environmental Protection Provided by MassDEP: ILIBureau of Resource Protection - Wetlands MassDEP File Number_ WPA Form 3 — Notice of Intent Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Document Transaction NumberBarnstable City/Town B. Buffer Zone & Resource Area Impacts (temporary & permanent) (cont'd) Size of Proposed Alteration Proposed Replacement(if any) f. ❑ Coastal Banks 1. linear feet g. ❑ Rocky Intertidal Shores 1.square feet h.❑ Salt Marshes 1.square feet 2.sq ft restoration,rehab.,creation i. ❑ Land Under Salt Ponds 1.square feet 2.cubic yards dredged �. ❑ Land Containing Shellfish 1.square feet k. ❑ Fish Runs Indicate size under Coastal Banks, inland Bank, Land Under the Ocean, and/or inland Land Under Waterbodies and Waterways, above 1.cubic yards dredged 1. 0 Land Subject to Coastal Storm Flowage 1.square feet 4. ❑ Restoration/Enhancement If the project is for the purpose of restoring or enhancing a wetland resource area in addition to the square footage that has been entered in Section B.2.b or B.3.h above, please enter the additional amount here. a.square feet of BVW b.square feet of Salt Marsh 5. Z Project Involver Stream Crossings 1 0 a.number of new stream crossings b. number of replacement stream crossings C. Other Applicable Standards and Requirements Streamlined Massachusetts Endangered Species Act/Wetlands Protection Act Review 1. Is any portion of the,proposed project located in Estimated Habitat of Rare Wildlife as indicated on the most recent Estimated Habitat Map of State-Listed Rare Wetland Wildlife published by the Natural Heritage and Endangered Species Program (NHESP)?To view habitat maps, see the Massachusetts Natural Heritage Atlas or go to http://www.mass.go\,./dfwele/dfw/nhesp/requlato[y review/priority habitat/online viewer.htm. a. ® Yes ❑ No If yes, include proof of mailing or hand delivery of NOI to: Natural Heritage and Endangered Species Program Division of Fisheries and Wildlife 2008 100 Hartwell Street,Suite 230 b.Date of map West Boylston, MA 01583 wpaform3.doc•rev. 1/3/2013 Page 4 of 8 Massachusetts Department of Environmental Protection Provided by MassDEP: Bureau of Resource Protection -Wetlands MassDEP File Number WPA Form 3 — Notice of Intent ILI Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Document Transaction NumberBarnstable City/Town C. Other Applicable Standards and Requirements (cont'd) If yes, the project is also subject to Massachusetts Endangered Species Act(MESA) review(321 CMR 10.18). To qualify for a streamlined, 30-day, MESA/Wetlands Protection Act review, please complete Section CA.C, and include requested materials with this Notice of Intent(NOI); OR complete Section C.1.d, if applicable. If MESA supplemental information is not included with the NOI, by completing Section 1 of this form, the NHESP will require a separate MESA filing which may take up to 90 days to review(unless noted exceptions in Section 2 apply, see below). 1. c. Submit Supplemental Information for Endangered Species Review` 1. ❑ Percentage/acreage of property to be altered: (a)within wetland Resource Area percentage/acreage (b)outside Resource Area percentage/acreage 2. ® Assessor's Map or right-of-way plan of site 3. ❑ Project plans for entire project site, including wetland resource areas and areas outside of wetlands jurisdiction, showing existing and proposed conditions, existing and proposed tree/vegetation clearing line, and clearly demarcated limits of work**** (a)® Project description (including description of impacts outside of wetland resource area & buffer zone) (b) ® Photographs representative of the site (c)❑ MESA filing fee (fee information available at: http://www.mass.qov/dfwele/dfw/nhesp/regulatory review/mesa/mesa fee schedule htm). Make check payable to "Commonwealth of Massachusetts- NHESP"and mail to NHESP at above address Projects altering 10 or more acres of land, also submit: (d)❑ Vegetation cover type map of site (e)❑ Project plans showing Priority& Estimated Habitat boundaries d. OR Check One of the Following 1.❑ Project is exempt from MESA review. Attach applicant letter indicating which MESA exemption applies. (See 321 CMR 10.14, http://www.mass.gov/dfwele/dfw/nhesp/regulatory review/mesa/mesa exemptions htm; the NOI must still be sent to NHESP if the project is within estimated habitat pursuant to 310 CMR 10.37 and 10.59.) 2.❑ Separate MESA review ongoing. a.NHESP Tracking# b.Date submitted to NHESP Some projects not in Estimated Habitat may be located in Priority Habitat,and require NHESP review(see http://www.mass.gov/dfwele/dfw/nhesp/nhesi).htm, regulatory review tab). Priority Habitat includes habitat for state-listed plants and strictly upland species not protected by the Wetlands Protection Act. ** MESA projects may not be segmented (321 CMR 10.16).The applicant must disclose full development plans even if such plans are not required as part of the Notice of Intent process. wpaform3.doc•rev. 1/3/2013 Page 5 of 8 ILIMassachusetts Department of Environmental Protection Provided by MassDEP: Bureau of Resource Protection -Wetlands MassDEP File Number WPA Form 3 — Notice of Intent Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Document Transaction NumberBarnstable City/Town C. Other Applicable Standards and Requirements (cont'd) 3.❑ . Separate MESA review completed. Include copy of NHESP "no Take" determination or valid Conservation & Management Permit with approved plan. 2. For coastal projects only, is any portion of the proposed project located below the mean high water line or in a fish run? a. ® Not applicable—project is in inland resource area only b. ❑ Yes ❑ No If yes, include proof of mailing or hand delivery of NOI to either: South Shore-Cohasset to Rhode North Shore-Hull to New Hampshire: Island,and the Cape& Islands: Division of Marine Fisheries- Division of Marine Fisheries- Southeast Marine Fisheries Station North Shore Office Attn: Environmental Reviewer Attn: Environmental Reviewer 1213 Purchase Street—3rd Floor 30 Emerson Avenue New Bedford, MA 02740-6694 Gloucester, MA 01930 Also if yes, the project may require a Chapter 91 license. For coastal towns in the Northeast Region, please contact MassDEP's Boston Office. For coastal towns in the Southeast Region, please contact MassDEP's Southeast Regional Office. 3. Is any portion of the proposed project within an Area of Critical Environmental Concern (ACEC)? Online Users: a. ❑ Yes ® No If yes, provide name of ACEC (see instructions to WPA Form 3 or MassDEP Include your Website for ACEC locations). Note: electronic filers click on Website. document transaction b.ACEC number (provided on 4. Is any portion of the proposed project within an area designated as an Outstanding Resource Water your receipt (ORW) as designated in the Massachusetts Surface Water Quality Standards, 314 CMR 4.00? page)with all supplementary a. ❑ Yes ® No information you submit to the 5. Is any portion of the site subject to a Wetlands Restriction Order under the Inland Wetlands Department. Restriction Act(M.G.L. c. 131, §40A) or the Coastal Wetlands Restriction Act(M.G.L. c. 130, § 105)? a. ❑ Yes ® No 6. Is this project subject to provisions of the MassDEP Stormwater Management Standards? a. ® Yes. Attach a copy of the Stormwater Report as required by the Stormwater Management Standards per 310 CMR 10.05(6)(k)-(q)and check if: 1.❑ Applying for Low Impact Development (LID) site design credits(as described in Stormwater Management Handbook Vol. 2, Chapter 3) 2.❑ A portion of the site constitutes redevelopment 3.❑ Proprietary BMPs are included in the Stormwater Management System. b.❑ No. Check why the project is exempt: 1.❑ Single-family house wpaform3.doc•rev. 1/3/2013 Page 6 of 8 Massachusetts Department of Environmental Protection Provided by MassDEP: Bureau of Resource Protection-Wetlands Mass-DEP File Number WPA Form 3 — Notice of Intent Document Transaction Number Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Barnstable City/Town C. Other Applicable Standards and Requirements (cont'd) 2.❑ Emergency road repair 3.❑ Small Residential Subdivision (less than or equal to 4 single-family houses or less than or equal to 4 units in multi-family housing project)with no discharge to Critical Areas. D. Additional Information Applicants must include the following with this Notice of Intent(NOI). See instructions for details. Online Users:Attach the document transaction number(provided on your receipt page)for any of the following information you submit to the Department. 1. 0 USGS or other map of the area(along with a narrative description, if necessary) containing sufficient information for the Conservation Commission and the Department to locate the site. (Electronic filers may omit this item.) 2. 0 Plans identifying the location of proposed activities (including activities proposed to serve as a Bordering Vegetated Wetland [BVW] replication area or other mitigating measure) relative to the boundaries of each affected resource area. 3. ® Identify the method for BVW and other resource area boundary delineations (MassDEP BVW Field Data Form(s), Determination of Applicability, Order of Resource Area Delineation, etc.), and attach documentation of the methodology. 4. ❑ List the titles and dates for all plans and other materials submitted with this NOI. a. Plan Title b.Prepared By c.Signed and Stamped by d.Final Revision Date e. Scale f.Additional Plan or Document Title g. Date s. ❑ If there is more than one property owner, please attach a list of these property owners not listed on this form. s.® Attach proof of mailing for Natural Heritage and Endangered Species Program, if needed. 7. ❑ Attach proof of mailing for Massachusetts Division of Marine Fisheries, if needed. 8. ® Attach NOI Wetland Fee Transmittal Form s. ® Attach Stormwater Report, if needed. wpaform3.doc•rev. 1/3/2013 Page 7 of 8 r Massachusetts Department of Environmental Protection Provided by MassDEP: Bureau of Resource Protection - Wetlands MassDEP File NumberWPA Form 3 — Notice of Intent Document Transaction Number Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Ba.rnstable ILI City/Town E. Fees 1. ® Fee Exempt: No filing fee shall be assessed for projects of any city, town, county, or district of the Commonwealth, federally recognized Indian tribe housing authority, municipal housing authority, or the Massachusetts Bay Transportation Authority. Applicants must submit the following information (in addition to pages 1 and 2 of the NOI Wetland Fee Transmittal Form) to confirm fee payment: 2.Municipal Check Number 3.Check date 4.State Check Number 5.Check date 6.Payor name on check:First Name 7.Payor name on check:Last Name F. Signatures and Submittal Requirements I hereby certify under the penalties of perjury that the foregoing Notice of Intent and accompanying plans, documents, and supporting data are true and complete to the best of my knowledge. I understand that the Conservation Commission will place notification of this Notice in a local newspaper at the expense of the applicant in accordance with the wetlands regulations, 310 CMR 10.05(5)(a). I further certify under penalties of perjury that all abutters were notified of this application, pursuant to the requirements of M.G.L. c. 131, §40. Notice must be made by Certificate of Mailing or in writing by hand delivery or certified mail (return receipt requested)to all abutters within 100 feet of the property line of the project location. 1.Signature of Applicant 2. Date 3.Signature of Property Owner(if different) 4.Date 5.Signature of Representative(if any) 6. Date For Conservation Commission: Two copies of the completed Notice of Intent(Form 3), including supporting plans and documents, two copies of the NOI Wetland Fee Transmittal Form, and the city/town fee payment, to the Conservation Commission by certified mail or hand delivery. For MassDEP: One copy of the completed Notice of Intent(Form 3), including supporting plans and documents, one copy of the NOI Wetland Fee Transmittal Form, and a copy of the state fee payment to the MassDEP Regional Office (see Instructions) by certified mail or hand delivery. Other: If the applicant has checked the"yes" box in any part of Section C, Item 3, above, refer to that section and the Instructions for additional submittal requirements. The original and copies must be sent simultaneously. Failure by the applicant to send copies in a timely manner may result in dismissal of the Notice of Intent. wpaform3.doc•rev. 1/3/2013 Page 8 of 8 r Commonwealth of Massachusetts d S o ty/Town of Marstons Mls op Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health:o determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, 3900 Falmouth Fl use only the tab key to move your Address cursor-do not Marstons Mls MA use the return City/Town State Zip Code key. 2. System Owner: tab Stop and Shop Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 03/01/2022 4,000.00 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: GreaseDPT(Grease Disposal, Pumping and Transportation Services) ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? X❑ Yes ❑ No 5. Observed condition of component pumped: Good 6. System Pumped By: Bob Brenton Name Vehicle License Number Waste Water Services, Inc. /Heritage Pumping Company 7. Location where consents were disposed: 03/01/2022 �Sign6ture o H Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 f l ENON WASTEWATER ' ZTREATMENT FACILITY - a earl rwN —I TNN IAR0IHG �—.� a s111 JAEPADM 1 1 --�— 'N' 1.$1.11 OD I_-----. PAD A o P a el. f r I>•C ovlurt Flo • a 1 R111 p ►w0 1 Y'�t't aor� b SN101' (—rs A t a e]U OI Ruee>12�- �•M�-( `�T1' h"REMOTE R•eaOT BOTTOM 9.N' .pR1�./'..µla \ 11 N SEPTIC TANK�A7�DQtla m OfA�I 1 rg Rl.I 11 co Q Rp) e-mx IL CL Y i` �t t' QVJ.�-• C J W 4m I° TARX NwH-m 5Wo m O p 1 R ais! ct CL 41' (4� NIEA 1.lP,lp V `• s I.91.5' I ' w R• aT-1 sm BOA') - V a ad m el.a I-9 51.17 _ 40' WIDE) e's MAR - eL e0'X72 " n.N mN " sl.lr I x•.u•Tsv _ ,.�•p� (PRIVATE -1 LEACHING 80""]2" I -•e�61O' ' Rom.P u R Y Y FIELD A LEACHING - a$a e'cw aeaa' vn FIEND •ee 0'9eN-I) Lee.m a y a a sm 4'�r n.M s7.ay efye B n.W ' 1 .we1����1�l! TCl ROOF mm eem 56a VENT R•Iaee�i\ � , I..71 11 . 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DELI 6_1O, LOBSTER FI H MEA q'-O" L'-10" F.D.❑ (O") F.D.❑ (O') F.D.❑ (O') 3'-II 3/4' (HUSSMANN 5EI IHUSSMANN D5E12) TA"K (HILL OSAS) (HILL OSAB) (HILL 03UMI2) (HILL 03UMI2) (HILL 03UM8) (HUSSMANN M4EI2) IHUSSMANN MAEI2) (HUSSMANN M4EI2) IHUSSMANN M4E12) (HUSSMANN M4EI2> IHUSSMANN M4EI2) (HUSSMANN D5LEI2) IHUSSMANN D5LE12) (HUSSMANN D5LEI2) IHUSSMANN DSLEIZ) (HUSSMANN D5LEI2> (HUSSMANN D5LEI2) (HUSSMANN RLDFHI2) (HUSSMANN RLDFHI2) (HUSSMANN RLDFHI2) IHUSSMANN DSLEI ) = 1 I �� I RAM STAIR ><2 4 ROLLING RACKS MEAT CUSTOMER o$ &I I I x= iI - -- DIVIDER m _ ;' ��i �I1 wl I w I UNDER Ile ■ PHONE 10'6' CLG \ EMER -i J ocm + €n�� '• I in EXI� d T E I oe°I I 'T N �- s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ - - �- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ _ _ _ - - - - = o m V H w F- ! 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' N DELI Lu m m �., i I 1 W LL \ iv< _� - Z I I - w U J a WORK N a \ } z I m p( 1 j I I I I z o AREA 'ILIs W ^ I f 11 I I N � I I O < U o 0 1 I I W I I I I I I _ °m = - m _ HOOD CTRL ( r I 1 I I I = PANEL FRYER I LL O_ _ DC cv -1 DC DC J I I I I I � 9 N I I = o s = I I t I 13'x2' DEEP ANSUL m O I Q N Z Q < TATION m of 2 DUMP w <= _ a J I Z Z X W Z Z I I I I ( f DC J w o '' rx J_ I • I I IS" SH cy F- O O Oc< = TABLE of ' w a I8'SH IB'SH 18•SH IB'SH w � Z u v = Z z i l'-9 3 4" I i CONQRETE P/'�� I / LU LL_ U FRYER gl ^ d I J tza rL x o I I n I v = z > - I � N �' x I _ w G Ul I I I I OH A I _ _ w o I I il0 xl3 DEEP! I ! I I W ZI I z z J W °° J > D! J \ oc 2 L F ❑ <, z J 2 s = s s s = in 2 w Ln N ui LL N N z I I I W 2 v W TABLE L m w I II = J J J J J tL W I I I CONCRETE 1 I to I I 'I I W W W W W W W W r ;• W J D: } o 0 0 w h u i Q X N O p I I I I I N 1 1 cn u) N N In In N N 0 U. 1 ( > I 3 I I I I x LJ w u_ N O Z U. O 0 G U in = a z ! FINISHED I I I I t m - in s r I- cy < J AD TOP AT cm u I D_ z I1 I I � BOOKS O a w o I ? I I in n N n N 4 Xs CARDS CARD 18'SH 18"SH 18'SH m ONV m I I FLAT P ' it I I I I I w mto ® m m m m m m m m _ _ +. I a m in Dc DL D! � it � [n Q � i GRADE — — — '— — — — — ry r VEN I "� � 11 I W I I — r N v M D m oc = < °` °` _ L _J } o! o �N I II - - In I I 1 D � Ln in m I I 0 I , I , I 1 LU I I O N Q • V ('V CV .. I I I I I I I I = M ` SCALE 51' HOT I r OC 8r I - m DOME 1 I1 i CL REFRIG 1 I Z 1 I H STATION - - � z �L I IQ 0 Q W - - - - - - --- ---- � � PRO UCE I1 UBAZAAR 10'-I' PREP D J I Ge REFRIGER TED LOW90Y oc } O N W I I > " STOR E FOODS G D`�h LL 11 P a a I I in [Q = N N N _ \ 3 U ,� x I ( v� in W ? Q . O O `r oc oc (HILL 02.5UMI ) O I - N - N w J > Cj > (k 0! 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(-1") a ry K FIXTURE f= — — — — — — — — — — — —— — _— — — — — — — — — — — — — — — —— — —— — —— _— __— _— — — — — — — B' X I', COFFEE DAR — — — — ® u7 \ O s. _ _ _ = 2 = _ _ = 2 2 S S = s x = = I _SOFFIT AT 7'6" -ROLL DOWN GRILLE - SOFFIT ! CL8 I 9( 1 I _ U U U U U U U U U U U U U U U U U U - — _ -_ _ _ __ __ _ _ - - - R 6'-L 1/Ys DISPLAY CASE9 IY/ DOORS - AT T-6" 4' CAKE • .1 (L - - - N I1 - - - - -- -- -- -- - - -- - - - - -- - - S$ 5'-0" W-0 1/8' REFRIG -0 l/8' REFRIG ]L J J 9 I W U) W OL Lu D: w w W w W W w W W W W oe C SHELF U 1 ►AaTRTcooRlEs DECORCN O W w w W w W W w w J > w ooNuia IRR11N9 L1oRN•a BAKERY CASE STATION BAKERY CASE HOSE < [? 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D CORRIDOR CURB DATE DRAWN 5/4/O- �, _ - -- I I N L I CARRIAGES m = O a I U I 1 RECESSED MAT O ! - - - - - -= ---- -- --- - --- J J J LINE OF LINE of I 20' COUNTER W/ BUILDOUTS OVER CASH o O __ __ I-T 3� J U _ I RECESSED MAT I OFFICE •+` -- I v - I I N �2 HIGH 3B' HIGH - - - - - - - - - - - -- - - -- - - - - - - - - - 6/IB/OI -- --- --- - _�.. RAMP O ! v 18� PRT N 3+�. 3 PRr N IP �j DATE I - Oi' o I _ PI ° - - SCALE: AS NOTED P O \ /: ; DOWN I - -`� - - - - - - - - - - I Ir ti+ STORAGE Q P I I I m STAIR t� ------ - --------- IF BENCH N �_ --- - Q - - _- 8R ® ® LINE OF F•b JOB NUMBER: k,.. 4 Q / I ® LINE OF ® i FULL HT +� ! - - - - - - - - - - - - - - - - - - - - - - - CANOPY - - - - - - - - - - - - - - - - F — J RCHITECT' U / _ CANOPY — — — — — — — -- _-_-____._ PRT'N NON-FREEZ q j - - - - - - ! STAIR al HOSE BIB / FULL HT \ fq i.. L �< / :o // -- _. — ------ - - -- - - - — — — — — — — — — — — — — — — — — - - - w ---- ----- ---- CL \ Q O < O RAMP _ FLUSH o RAMP O a<, p p z a p a 0 20'-O" �, DOWN PAINT DOWN in 20 -O" LINE OF H I = LINE OF it H Q SIDEWALK w Q ENGIN 'S SEAL L in 48'-6" 14'-9' 30'-0" In 105'-G" I � 30'-0" 14'-9" 8 -6 0. U O U] 8" I6'-O" l2'-2" 65'-4' L6'-10' 40'-2" 58'-2" 8" NOTE: - _ 340'-0' ALL CHEST AND FREEZER DIMENSIONS !NCLUDE WALL FINISHES a- SHEET NUMBER: i W Fe F-1 O J n REMOVE EXISTING 10" PLUG AND y 7� r � CONNECT EXISTING 10"" WATER J MAIN TO NEW 12" WATER MAIN 0 7�19 r- 12""X8""X12"" TEE w �.. M 2 - 12" GV � 3till 1` �� � � / � Vanasse Hangen Brustlin, Inc. / �� �� ---: - Transportation 0 '- v. _ _.._ _ _ __ __ � Land Development - -- --- - Environmental Services 1(j� - INCLUDED IN THIS CONTRAC u P.O.Box 9151 GAS 1 o„GAS - _ 101 Walnut Street, \ - - Watertown,Massachusetts 02471 617 9241770•FAX 617 924 2286 -/` 12 NG eQ 12""X10"" INCREASER _ 1 - 12"" GV ON ,. INCLUDED IN THIS CONTRACT ". CENTERVILLE-OSTERVILLE SI',:►E r r r REMOVE XI TING 8"" P U AN q p v r EXISTING L G D � M�r CONNECT EXISTING 8"" WATER i ��UIF ti'Q �"R,n� 40 MAIN TO NEW 12 WATER MAIN �� ��'XI�j01V / SOT �i'V 0F 1 { / FES-31 DMH-23 N ��Sr1Q/�T r I=48.30 OU R=60-9 I=57.70 CB-19) APROXIMATIE LIMIT OF WORK TO BE PERFORMED I=57.70 (OUT) UNDER A SEPARATE WASTEWATER TREATMENT J DMH.8 FACILITY CONTRACT J R=61.8 I=57.10 BUDG) ~"�1 (SEE REFERENCE DRAWING C-16) i I=56.90 DMH-2 ) _ •-------•-•----• -•--...--•-•--•-•--•__ _ LS-1 I=56-90 (OUT) ___ ' -•- ........................ _ __ - ` R=64:.1 MAINTAIN AND PROTECT 2 2" PVC -�' I=55..4(l SMH-9 EXISTING WATER AND WG _ - - TREATMENT '` -•• IN =54 3 GAS SERVICES •. _ _ fi p _ .- _•, .• -_ FQRC o(SM 4) (TYP.) �"W =_ ` .- _•�--• OO GAL EQUALIZATION A�S' \ � ���" FACILITY 0! DEEP _ M H 1 � 22,0 QUA _uNOEcxccxouNo 1REA TlAEAiT TANK SHALLOW 10 LEACHING CHAMBERS D _ 12"p --.:---TANK & PUMP STATION _ _ - - _ - UG£ GE TO ENCLOSURE CB- 1 - 8' DIA. - RNE __- _.- -- __ = 513D SC-4 _ GENERATOR-MD R,,,AND ENC 2 R 66.Ot _- .- �z- SHALLOW =I OUT) �b UGE/T •- ' _ `ry -----. _ _ _ J . / _ - --•_-- _ / VAULT ����''°"•-•'•�'_.,*.-^,.. R _5 I 61-30 SC 4 _ � TRANSFORMER PAD ( I � M - -'_"-_ - 6�l 7 _ . PRESSURE DOSING': SMH 8 CB 20 �` I 50 � . R-67.3 R-68.5 DMH-33 DMH 34 MCti 2 iy _ v/L /^% `' STATION WITH PUMPS 15MH-9 I=57.00 SMH-7) I=66.00(OUT) R=sa.B R=67.9 LD !-- _ - _ "(� -?' _ IR=65.8 I=56.90 OUT I=65.20 (CB-2- I=63.80(DMH-33 I=57.50 UGE/T _ FF DC629 8 !'=56.40 SMH-8) I=600(CB-20 I=63.70(OU P { UP ��„„ ® - E �!=56.30(OUT) I=64.70'(OUT N BAStN 15 _O}{W- /! LD Ik� 1 ti _ (/ 64 S �_ I=59.20 OUT) ND , -1` R _ /�� 11,000 GAL.'_ f' cN �- MAINTAIN AND PROTECT Up =MAINTAIN &`PROTECT - "' �` .-- .__._._-- -- `_ = ' EXISTING LEACHING CHAMBER / ! DMH-30 LD SETTLING 6-PVC �. 6 3 1 EXISTING GREASE TRAP EXISTING HYDRANT DM5o.9 DMH-36 TANK D ` C / -- '"-� RIM = 64.8 /�/� l f -` - _ TO BE MAINTAINED/ f + I=48.80 (DMH-29 - �,� _ -: ^n=65.5 -INSTILL 12"-4s• B�rtiD r ' - 1-1:- _- r' t' _ II=48.70 (OUT) Yp J , - I=56.50(0UT) AND CONNECT TO cz �- F �' '�^ tub_ # SHALLOW - �_ - °0 �' I / EXISTING WATER LINE - - " _ - 4�+"` _•-- `12 D_' a 4 40 i I !y d VALVEMANHOLE . - /�////j, DMH 29 DCB 19 SMH-14 c� ,- - - �_ - _ REMOVE & RELOCATE �r 12 D'"" C / .'� R=56.8 R=60.6 `� a'` -EL.+4 t 8"S - 8"S- - - r r- -- _ �� I / R=64.4_ o z /EXISTING HYDRANT _- - ___'� _ _ .--r -, ,... _, f 12" PIPE I=50.10 DMH-28 I=58.10 (OUT) I=54.80 SMH-13 I t �_ _ _ . .►oSF�WER T� / - __ - i / I 50.00 (OUT /1 ) DMH-37 12 W -NAjER _ - I=54.70(OUT) 1 2-2" PVC 1 ._ - _ ---- ��_ ; �..-•s 5 --63.9G� _ ELOCATE . RELOCATE R=64.2 �/ - - - YD ` ---- Rig,a _n4` $"S -mil. -.`.:GAS GAS METER a 1 s( �' HYDRANT FORCE MAINS wG r, I=56.80(DMH-37 ) 12"" LVL h[)PE Q 11 71 I=56.50(OUT) • l +.. �.." '6_- --"� r _ =64 �� - \ -'STORMCEPTOR UNIT F ==� _ BUIi DING _ � a �-65�.0 )�-•� GAL c%1�' ;�; � � j�Q � ' _ - _ ,. SO �8 _ r�,. t.o00 j/%/i I • SC-4 - 0 +w`1 Mtn c,RSaS£1RAP 'f/ .-�- . 1r� �+ R=66.4 �900 N PROPOSES. STOP & SHOP N J t - - -- } I f , c I=61.75 DMH-35 -_ . I I I I 1 I- '..4 1- 1` I I ,1. .1! ,I� �I� �I I r _ x `n 1._!. i s ;•`/1/////1 / f(�r s\ ._...-...--,; / ,x ,j: :; � ,,, SMH-5 ,� 1,00,.? .'ice'. ,f !Y� r I=61.50 (OUT) .. 12"D I I I 1 1 1 1 .L-1 + t l l l I I I I I / - I=58.00 i_1_ +--r~r , I I I,1 11 I I I I I 1 I INFLTRATION BASIN'I t I I _ - ;j///////�d 1 R=69.1 cPRtNK '' L" RASE `� i 15 D". l w / SUPS- 1MARKET a,t,rli t I,t .! I I 1 I. 2� CvLTEC tjNITS _ , Z I ® I'I 1 1�1 I I,1,1 1 1 1 1 1 1 1 1 i 10 0 11 1 1 1' UNITS WIDE 1'1 1 1 1 1 8 GA / E- -+,^ /i y I=58.20 SMH-4) «,, 6 /// I=63.50 i. DMH- 7A - - I I I I t I I I I I I I {, / / /!// ` l I=63.70�BLDG) t DMH- 35 N E = 65.0 I I I I N I I 117 UNITS LONG I. I t -- / r' R=64.3 -. ,pp- t� t 1 DMH-14 I I f. I I,,,,, ,,. r r r�r 1 /�// �`'�- SMH-6 I=sa.to(OUT) ti.� : `� HYD WGa t R=66.0 o R-626 1� -' - 1 ` I=so.00. RD EN 0 y .. 11 I=587o DC&-2 1111111 I I E., ARD S�T� f -I 1 1 I 1 �: SMH-7 4 4 R=sso SMH-4 �. T cp =' / 1, I=s2�o DMH-34 I 57.50 (BLDG) I I I l l l l l t l DCB-8 t I I I I 1 1 1 1 MAINTAIN AND MAINTAIN AND I R-63.2 1, R 69.2 I 58.00(SMH 5) R-68.2 4, ( f / - _.__._----- "" I=57.20 (OUT) 11 I=58.40 DCB-16 1 I 1 I I _____ - 111I - I I I I I I I I t RECONNECT /. I=57.70(SMH-6) PROTECT EXISTING I=65.00 BLDG) PROTECT EXISTING I=59.10 SMH-3 I= 00 (OUT) / w =-.w I I=59.10 (DCB-8) I I I I I I I 59.50 OUT) : I I I _J _ SEWER CONNECTION r-57.90�OUT) SEWER CONNECTIONS f/ f// -- I I I l i I I I 1 I I I GAS LINE R j, I-64-50 BLDG) ,r I=62.30 BLDG) ., " `y. SHALLOW I=61.00 I I=58.40 oU1� ---�r I I �; I I I I I t ,; ����� ( - _ I I I I I I I I DMH-15 I I I I I=57-60(OUT) j-;;i I=59.00 OUT) 1 111111 I 1 D 12"D 11111 �1 / 1`---_-_. __. -� -. �-- I DCB-16 I I R=s2s � (7j�1R�� / �` � l/f%1/ Ali/" � � � SMH-3 ' - � 6 S � � r� + u� '' DCB 22 � f HYD INFILTRATION BASIN __ I , /, // ss:.. - / ;w RIsE R=s5.3 / 225 CULTEC_UNITS y 11 R=623 1 1 1 t 1 1 I I 1 I I 1 I I=58.30 DCB-17 I fl 1 11,1 I / / l///, i /1: ��//1�f _ _ IE f' R 1 -_r :,, 1 I / WIG _ _ __. - -- - dH S - 280(OUT} t 1 I=58.60 (OUT) 1 1 1 1 1 1 I 1 I ►� I t I I! I=57.t30 DMH-1 I I I 6 --15-UNITS WIDE I= ,, _ �` 1 'IL,--61.00 J)� .EP 0 L 3 FROM / - -_ , tI I1I1I11I1 cps I1I1 tII1(I1I I ( - _ _�Q _ � I j. � I 1 f I �' � � j ///��/f I -- � � TI TA+�:' � � 1�•' S i / !� r:D ; FROM HDJGI+v�i�v - 15 UNITS LONG ` II' /f/f�/, RM R NIT f /: r - q/� I=60.'0i JT) n R 6 3"r: ' I '! PRt�PcRTY OATO LOCUS I DCB-17 1 1 I 11 '' I ( 1 1 _ <' PERT-60. 'i i RECONNECT BUILDING r R=623 100 DI�-16 ti s _ S I I I I < I I I I SC-1 - I=61.00 � m I 1 1 1 1 I f-"t� /-" �' p -----"" �• I I I=58.60 W t t � � I I k I I 1 0 0 SMH ��_` , �, ; R-66.5 600 r, I I I I I R�82 6 I It'T © i_ /1 - ////////// t SEWER� � w � 1 �� + • y WE T 3,�� OUTLET CONTROL p _ x •_ I I I I 1 11 I L I I I I'=58.60(DMH-6) r- - E STRUCTURE -_.--' ' '1 I=57.30 DMH-1 I I r I 1 �,� I' � �� ( ' RETAIL / I I I=57.30 DMH-1 I 1 I I I 58.05(OUT) r-�_ 1Q- Q-, �^ -, SHALLOW DMH-28 I I I lii 1 I=57.10%OUT), i I i I i I <, 1 ; ' L-_-I 1 \� I = ''� C, M = MAINTAIN AND ROTECT I DCB 1 f W I' _ r EXISTING. WATEf A D =a. R 66.6 1 R=59.2 4"p 1 , I=50.80 (FES-2 _ 8""F 4 I 1 D '^ _ 68.1 CABLE CONN- PIONS N INVE R a I=64.1 (OUT) '. I=54.00 �1;2oU ,,_ 1 - - 0(D -5)=56.00 R) - X 130" LVL HpPE �- 24 D 24"p I-59.30(OUT) CONNECT' EXISTING ROOF DRAW t Y�IFES I=s3.000ur) r _ �`L DCB-26 DMH-18 o - #� • , <' fTO LEACHING CHAMBER WITH � R=61.3 R=64-3 DMH-17 I T _24 D � o0 'L MH R 0 6`i-60-O0 RD s R=62.4 \1 I p-65S-27 "" / G - _ -- - I - - I GASOLiNEC 6 D.I•, - +ov I!=60-00 �rcC I = 0(SC- _ - �� �` - = - - _-_ - N _ I I� h ss.� 1) �� 1 r 1 I:- +._ , ,::-_-• NI _ r-bo.Sll�futon-15 I-- �J'Ct! ?_"n ---- " + ' -� � I 57.85 SC � �'- D L-_ _i I - I DMH 25 >� �o.,c; `�. 1, 12 R=61.2 I=56.50 (OUT) ® II 8 - - L WG �� `�.�� / --' I=55.60 DMH-24 I • � HYD � T I=55.60 (OUT) SMH-13 -- I - \ ate, °' }\ rowwNw t R=6 5 1 v T E R=64-0 _ --- _______________ Q R=66.2 0 ANti TRANSFORMER PAD - I=57.40 (SMH-12 ....�"�, �' J �---- -- --- � -----_-_-_- I=61.70 CB-7 .�rL �� �� � REMOVE-^ �- 1 54.00 ,,,., 1 - - o s N Dce-5 1 / ELOCATE__----- I=56.60 (BLDG) O } _-_- ---=-,•� 1 �. DMH-13 --- - � I=59.80 (DMH-4 i?=66.7 �'- _v,:�, � 1 '�,, � t. .,�,.rr ._.--t 1n DMH-26 I=56.00 GT-1 r7 i F STORMCEP70R"t1N1T 1 I R=62.5 -_-_- 6' DEEP I=59.80 (OUT 2 _ ( ) i -_-60 x72- „ STORE' DEER = 3 00 (OUT) '"-�- Y NOTES: - R-61.0 I-61.00 t _ 12" I=57.00 I=55.30 DMH-25 I=55.90 (OUT) ' �� LEACHING S�-� I=59.10 DCB-i 60'x72" [4CHING CHAMBER 1 6 r H; JP `IN����� 1. PUMP AND FILL EXISTING SEPTIC TAN I=57.10 (DCB-26 6"S I=60.00 - , -- R=62.5 400 -► I=59.20 DCB-2 _ . STORMCEPTOR L'NITLD LEACHING DM 1 I=55.10 (DMH-39 GT-1 a I=56.95(DMH-16) 1 12 D I=58.20 DMH-1 --- R=67.2 6" DIA. H 4 I L Ex S G SE C TANKS. --A ` I-- -FIELD ® 0 R=67.0 �, t, R=63.8, 63.E '� I=56.70(OUT) I=57.70 W I =63.30 BLDG) - 2. VERIFY EXISTING C:iiLDl_ _ A y.. NG SEWER INVERTS SC-3 #2400 I=56.60 (6-DI) S GW_I=58:60 - - - • - 2"D - I=62.60 DCB-5 - r-_--_ B _ I -57.30 BOTTOM SMH-1 " PRIOR TO NEW SEWER INSTAY eON 1 R=61.6 ` I=55.20 (OUT) I=56.45 (BLDG) I=61.00 F--- A w I `- I ALLOW --- ) 0 2 - (( ) IO 1 R=71.5t r"a N I=54.60 (DMH-26 I=56.20 (OU1 4' p / I-60.80 (CB-6 DCB .6 4 -VENT --- DCB-15 DCB-25 --- G 1 0 1� iti I=sD.Bo DMH-3 iN R=67.6 3•f i, "' SMH-2 I=66.30 EX �- ¢ X3. SITE UTILITIES (WATER, GAS, CABLE WITHIN I=54.35 (OUT) LD LD DCB-18 EN _ __ _ f = -----1i = 1 ( R=70.6 ( ) ) a i TO ROOF --- R-61.9 R-627 N I-60.30 (OUT) I=64.00- (OUT), oS.00' I R=60.E 1, I=59.40 (OUT) p I=59.40 (OUT) I VENT f " OUT=65.83" I=65.25 (SMH-1) I=66.25 OU UNDER THIS y ----- I I --------_ , g 18 D �-12 D I-65.20 (OUT) l.- j' CONTRACT.TO BE CONSTRUCTED U S I=56.90(OUT) �. / _ =__--'=- co - - ----- = INSTALL FES-22 -00 -- p 0 ll� ! ;`' I=50.0 (DMH-21 (- DMH-19._ - o VENT _ (I ~Z t - S STUB 4. SEE SPECIFICATION FOR REMOVAL OF -- -- , " < r 3.J 44 2' ,.`r a, c & E P. 'WATER a1 co 0 CB 7 o DMH-2 t r INSTALL w- a rr 1 R=sa.3-. . . it . I -- -- --- - - DMH-3 U 8""S ER t EXISTING SEPTIC TANKS. f--- SHALLOW 1--- W W R=65.7 N R 68.0 � , c� -, DMH-12 R-67.1 iy 8 STUB - _.. I=60.00 (RD) C 4 r DMH-39 I=57.50'(BLDG) I. I Ql I )CB-14 I R=62.5 _I co J I=62.00 (OUT) I=63.70 -4 I=63.60 DCB-2 EOflrIU��11Ot4 4 ' R=60.7 I=56.50 DMH-18 R=61.9 I I=59.10 (DCB-1 I O - _ p I=63.70 B-3 , \ - I I=59.40 (OUT) 12 D I=59.20 DCB-1 I-61.00H-2 ,-:, , LiACH1tJG LEACHING I� ® C f I=56.80 DCB-3 I-56.50 DMH-20 1 I i Q I=6230 DMH-1 I I=56.50 DCB_ ~ I=57.70 I 60x72 ll I=61.80 OU MAIN IN AN PROTECT I=59.10 DMH-11 1 PkSN I=61.00 OUT) t'S ( >7 <. I �} N _ '% EX ' 15"D 12 D I=58.70 OUT) RESERVE w LU , 00 �' EXIST G WA R AND ' I-56.40 OUT) "DI GAS Y ) -.=- , •r,,�.I 58.00 �, I 60"x72" ! � �- - _W CB 6 ERVICE (T P. �a"S c �. � SHALLOW LEACHING AREA z C - MH i 6"W ' RESERVE I o I � w `:+`= R=66.7 D B 3_ , D I 1 DCB-10 G I=63.90 R=67.6" R=6�_ - �� I I IR=62.7 I� I=63.00 OUT I=64.00- OUT I=6')0 DCB-1 1 EX SMH _ 1-61.00 J LEACHING AREA 0o M❑ _ tp - 3- 1=5g.40 (OUT) I=6� 0 OUT) R=71.Ot -INSTALL _ 1 ( EXISTING BASINS TO / - -- / r NP+; _- o ---_--- 3z v1 BE REMOVED TYPE s Ex 4" DMH-38A p _, - ,., i=s66.50�8-OUT) J _ ( ) ROXIMATE LOCAi7DNS -PLUG R=60.E wG OF SANITARY Pi,� II 1 I=57.40 BLDG I=57.30 DMH-3,) /l l © 0 8 ® M INTAI EXISTING - I=57.30 (OUT) �" �-30't5 �-30"D B ILDIN CONNECTION • • �' wqw4 J =' M INTAI AND PROTECT, 1 �, �j 12 STTLETRUCT CONTROL .= 8"W RMH 1I 15"D �. 8 W " 8""W 8"W SOWER TO INGO • D '� -,,".....,. � ,�•^ .._ - ---i :� TI HT'�T NK AT � "'�- --._.._,_ I SIDEY�p DMH-21 12"D STRUCTURE o 2 f 15"D 6 W(TYP) c� - - - - - - - - - - - - - r (� ANERS TIGHT TANK _ L- SETS t R=62.3 DMH-20 - �. 6"S - - - - - - - - - - - - - - --65- - - - - - - - - - - -6 S- - - _ . I - 57_60(DWH 20 �l - ---1 RM64.5 , r I=60.60 (CB-13) WG - t ) i I I=52.50 OUT)-,,.. 7 / ��� I=61.80 DMH-1 �-12 D _ (' 1 L=60.5Q»(WE1R � � 69.0 HY I=59.50 (OUT) 1 - ,f rt: I=60-00 (RD) I CB-13 r t I-56.50 DMH-19 R=65.217.DMH 38 r ( ,?=55.60 (OUT) I WG • I 1i=61.50 (OTT) n t h �HYp, i ==^-�I SMH-1' I ' I 1 z TAPPROXt ` w R=66.5 SMH-10 R=..644 -° � o ,�� _�^_, rV;,_. � I P�iU�OSED = TE LO AT1O ;3 ""W(�P) I=57.90 CB-27) 8 SANITA )IT AN SEA. I=57.90(OUT) =8 W 1 FFE= _.� sHALLow R UAlL � U' 19 ,� MAINTAIN AND ) I=62.80 SMH-10 R=69.1 SS SMH-12 -' DCB-9;-, I-62.90 BLDG E I=65.00 BLDG) �_ - J T) S 8" �PR 1 1 TEAM COMMENTS 9 13 Ot 67.d' f� R-65. I-64.00' I=63.50 BLDG D I-64.90 (OUT) 8"'X8""X OTECT EXISTING - SHALLOW t U'f 4"CI-, L I-62.70 (OUT) 6"X8"' REDU}:�R CONNECTIONS NPv �� INSTAL j R=64.8 -� I=63.80 _/ N � UTILITY No- Revision Date Appvd. DMH-20A /=� STUB I=59.0o,kwh-11A „ o DMH-10 -� - FFE = 67.7 ffi " " R-63.1 I-58.90(OUT ' _ SMH-11A -1 '. '- Il _ Desi ned b Drawn bI=63.00 RD) - ,., ,, SHALLOW - _ '` �� , 9 Y DH y WH DH/EM 12 X8X12 TEE _ _ cv R=67.3 R=67.0 R�689 �, f Checked by 0 (oUT) �� 1 - 8"" GV r-:_ I_=_60.00_ R9) __..-_. _.... __ _ ------- ----._ _ --..----PROD." ?It SETBACK LIN,i I=63.70 (CB-12 I=60.90 (SMH-11 GG G � � � w�,v I=65.30 8 3 % /, _ CB-23 - CAD checked by Approved b 2 - 12" GV CB-27 I=54.60(DMH-20 BICYCLE - I=62.50- DC@I;9 --Lv&fl.80 (OUT) '= r / Y 9 1 R=62.4 I=54.50 (OUT) �>7UT) -_ v _ -- - _ - - IR=68.8 I \� _ , �. I 65.00 U ��� DH SHALLOW 6` DEEP I- - - (OUT) Scale I=58.70(OTT) SHELTER CB- -- _ - 1 =40 ate 8/02/01 _ - __ 1 DEEP-,..-^...-� ,- , ,: r_,yam--,.. --,_ .- ,. - -,,-v ,. , -� LEACHING CHAMBER . . / , CHAMBERR-6lp':7r _ - �-- Project Title LEACHING 6'DIA: --- .-._ -_ r 1 r R=66.5 6' DIA _ '.® I=6k>.2 (OUT) If=64.00 BLDG) R /�IL C L J __ 'J I=62.80 BLDG) _ _ _ �I=5a_OO�BOTTOM) 1 I RETAIL C Cotuit Landing n Jy I-56.80 BOTTOM) - _ _•• --- MAINTAIN AND PROTEC! WAR _ -' 1 1 3 -'• vnn v _ N _ .. •- TING UTILITY ' ""`''`^^F '` 2" _ ,- EXIS i r r-, - CONNECTIONS • ,8638 --. - -•-•• - _ vW_-A ;, _ 10 - j Redevelopment- •- t _ r r _ ( S ". .` ,,EUT ND CA6P - - _=�. y��.� nnnvv ,�v 6 LEAD�CRHING CHAMBERS 1 -_ u < - . . . - . . . _ON4e- . . . - . . - . . - - - - --- A LINE ' ._ .--•----•--..- - R=71.0 8' DIA. cQa �, f - _ . . . _ - -OHi�_ _ __ - - ---- - .--•- .--. ... _ (B G) and Expansion _ _ -� - 4_ - . . - F}q I 54.0 (BOTTOM) , �. _ _ __-- _-_ -_ ^_ Barnstable Massachusetts _ Issued for h 'i - __ R Bid -� - _ Q - G S �- - y�Q STORMCEPTOR`�UNIT------ V l ,,t INCLUDED IN THIS CONTRACT we - ` _ A - GASC-5 - Lv ---- --- - �-_ - - _ Q s _ _ . . .- /�/fit. ` /�,'V r ; y t. v` �ti- y r�1 UG �"-- -- _1, _ . ,�.^ _ OUTH RO - ----- -- -7 - R - - 10 - G - _ _ ______-._.----- -____-- ....,. ,....,,.-�,�.-,. r' .,":r•=.,y,-'-----_._._ REPLACE 4"' WATE �' I 64 70 CB 24� 6,�5 __ - -- - - = As WITH 8" WATER I 64.45 OUT) __ Y v �- _ S Not for Construction INCLUDED IN THIS CONTRACT _-_- ___ _______ _ ktC-LODE[ 1N_THIS CONTRACT - Drawing Title ��__ __ _ �•--� 12""X12""X12" TEE ` �� z^ - _ -- 12'" PLUG t � � ti REMOVE4 6" STUB, Utilities Plar. 12 GV (3) �\ INSTALL- 8""x6""REDUCER 'ti, _ ""-'�- -_----------______ AND 8''-GATE;VALVE o 'f APPROXIMATE LIMIT OF WORK 1 TO BE PERFORMED UNDER A SEPARATE OFF-SITE � APPROXIMATE LIMIT OF WORK IMPROVEMENTS CONTRACT f TO BE PERFORMED UNDER A N SEPARATE OFF-SITE IMPROVEMENTS CONTRACT (� Drawing Number ;I ' 40 0 40 80 MiniI , � / -7 4 SCALE IN FEET t / `_---- Sheet of '� �'_' i /( 7 16 IProject Number 05162 05162\...\Permits\Local_Approvals\5162ut.dwg ./ . A .F`+n..7��,v - w' A• ,k•: rcf . `•9 . _ ._ .-w. .. .w.wr-...-o _.-._.....u„� ....,—►-w. _•.. _ _.... .. r. , PLAN OF LAND I r ._ � In BARN E MASS 4� le. /--'7 .0511 Alt- - ----- T. �%. . \ '� Showing 0 de oe Proposed BuildingEk Sewage System Layout T t .y `\�� I -- , �' i T ! / ,'f Z,i T -� amac. V �-,-- --� ,� TNF RUSSELL A. WHEATLEY CO. INC. S' LAND SURVEYORS FN6INFF S e� JON - ati: ,►� vita I 700 REDFORD STREET Q , 147 4. ' r� �.. ABINGTON, MASS �. ,���,c NAt i1 \ C' 7— t / /.7.•fir /4 t..,, SYSTEM � �, PROFILE (NOT TO SCALE) See a e Pit � p 9 DIStfIbU1b7 _ B0x Seotic Tank Foundotion // •0 18 Minimum 24" Minimum 1 Access Manhole 24' Minimum I I ,/% ,r ,�- .c ,• `�� .� .^, •ram �0 Access_ Manhole Access Manhole / • ell / Top — T- Soil 4" Unperforated � 1 i . --4 Unpoerforated Pipe - -1 ; r; \ / r; —� —r— Ca s t Iron P)p e ' Slope at �'_ Per Foot L X +� � ` Slope oP r Foot r y �► w �l ,' , ' �+f �F+r �4' O . j '� � o \ ✓ + e a Mini mum of 2 — e /41- C I� tQ I/ .. .. Q - --- �� 2 o- o o r o D • ' ° -- - ---r Flow, _ Ling -- - :.._ ° } Wosned Stone \ o ° 0 0 0 0 0 _o % i M --off „ ,4" Inlet Tee 4 0 ut le t Tee-- �� -_ ° o SO LogSo11 Lo ° , o o O ° • e �/ — '� \ 9 ' 0 O I of Design rjI'It rI ° • • --- --- — --- -- -- /- — /�--- —, Test Pot No z_ Test Pit N ° _ a C 0 D —— 1 --— --- — - —- • ' e ° o ..... r `, ./., 4. ✓' tir,. I r••�.../A 1. x" \\ ' J • Q o✓ O J , Y a• c • 0 0 0 of o 6 Sw° - --Y-T-rT 00 00, � T o ���' o � T•c � -'> a � t � J ,. � . '3/4'' to I I/2" Washed � •� � - " •t�' f `' ' C .� � � o r' ..-••- ,L.' ,�•• . �`- � :.'' .,�� .r .✓ c., Stone � I 7� .� s .� �'- �,�• ' .v '�' -' r f a T r` �� a-- �-' Invert In _ •. _ !r,yert !n = - Invert In Foundation s e _ _ Invert Out ,nver, Out _-_ — Invert Out I �' a �� .t ,c �"' ,Q r� �i �" � ��, •t,,% Fi�� h d Elev. y � t ' � _ L/ner Site -� Finished Elev. � ,f � Finished Elev. Finished Elev. Yee Q ,4 , ,. , .� 1, Le ochin Area � No. of Outlets�, � � rank �'a ocit Rood E/ev. Ile - - ----- — _ Notes j � PERCOLATION RATE %�*�- � ��� �PERCOLATION RATE.__.._ _� � ,� / �,r, ,�, / •�',�� �, y � � � � �"'Q I ' I. THIS OFFICE A40 BE NOT/FIED AT THE JT!MF OF SEWAGE SYSTEM CONST I F TEST E�E vAT1GN _ ` �' TEST E L EVATION_ _I / , _ �(ICT ON 0►P INSPECT iON, 1 fir' :� 2: ANY . SOIL CONDITION JARYINC FROM THAT SNDINN ON THE SDII LOGS SNAIL 8F ASSESSED BY THIS OFFICE. -je_ '0 DATE OF EXAMINATION__- t DATE OF EXAMINATION_____—_______ c9 r� A �y 3. ACCESS MANNOLES MUST BE CONSTRUCTED TO WITHIN f2' OF FW5PED GRA)F AT SEPTIC TANK ANv SEE➢ACE PATS. STABL 1 L3 t , I Q v5E E.L. Le C3A2oti) 103" MA2tLE1] SE�c/E�L �cll 1 HOLE IIJ p X m GEh]T1=2. F GOVEl2 02 t-Q-l�,t- • PICAL. F AL_L UJV (TY OQ- �-tZS I DIST. Blox • o� C Q I VEIJT m ! : = 4 21M (o8-f0 _ fzlM�cl - CoS.SS 2tM�2 - l010.05 _ 21M- CoCo.3o IZIM ELEV. VA2tE5 121M= 10&,zD RIM=GS.•70 RIM - C.1o.30 t + GOIJGRETE BIAGK LA.lD .. .. V111 •. - ,, ,.. .. I ( W WLI- BED OF in1VE2.T TO SE i• : . J 1 RE'p SEWFUR- 1 I` MOfLTAR. WITH /2 TI 8R1GtC. CONCfzETE SACZREL_ SLOGK.S 02 A ^" t OF PAR.G>= NG DoU COUQS OF 1ZE 1c/E2 i ON THE Oc)TSIDE. ': '.. ;. gLE E D _ r Z d ,•. ._ ;:: .. .: � B2lGlL SET lN� A. FULL BED OF• •:: .c u4 0 - ., p E I T`CP =02 ALL C N M ' > 1 _. Z4 24 PROPo5E1� V. !0 5D235 , „ P2ECAST C- C I G C M Lo C. 5 N. 5 t. , L A H tJ PIT BY LO AL A E�E2 1.20% (�ZOp P.V.C.5E1vsR'" Z4 Y 24� G, SvIZ35 . , . . ,.. •4 St�2"35 P\/G. DISTRtgUTor_ OF- 2.OTOti1G�7 c SONS (o PVC. SAI``7. 5 .. . •. , (0490 _ o , ItJG• #K C EAR (Q(-. I-'i �Z. I :.. .� 11 i 11 •'t , 11 ' E' p 2rj 5D12 3Z. � Ge_5 lS S Fp2C _. . -- . 11 , _ 60.54 N ® MAIN :_..' �: A OF �S I2 \UAS"ED SCONE 6000 _ L 59.50 58.50 t.� ... ... �. _ • .• -f0006rALLON _ 4 2ElN FOP CED 6006. 5 _ ram'EPTt C. T K o .. . � f4 � ASH7✓D ST FS 1` i2 p -. - ,. . ... . . . , OUT L.E _,.'• „' S - _ 9 T ! Schedule of Invert o � PIT c� : DIST. BOX' 3?p Invert into septic tank - 60 . 00 1 _ G(zP.VEL BAST_. . a a a D . • ,.. - • ,. .. e_,. .; ., TO BE LE\1E1_ Q.tJt7 STABLE r, fl Invert out of septic tank 59 . 75 b , e e t pt chamber - 59 . 50 Lro1J q Invert Into pump 13 U chamber- 58. 50 Invert out of um S� ' G 4C. - 44 n pump PT1 . TAN -1 Wlpc SCHEDULE OF TILT :BULB SETTINGS , o- distribution box 66 . 00 .1 Invert into D STA r . TO B V L 8 L..E , >✓ L� E AIJ _ 1 box 65. 83 ' 4 O f dist ribution ion -_. : _ Invert tt3oT-r-o 0 F PtT O_ _ INSIDE E BOTTOM OF PUMP CHAMBER 2 I 5�4 _.. _ N D O U C 5 3 . 0 Fes` P UM A 40 C N M B o leaching its ' _ 1 Invert in le n ert t . _ IyEAD __ P PUMP OI\I P,� ELEVATION 5 T.'•:-•�-0 I • . LEAD PUMP OFF AT ELEVATION 54 . 40 POSI=D E C N O A l-1 t U ►T P HIGH WATER ALARM ON AT ELEVATIOtN ELE`,/. 57.50 To 0 5 8 . 0 0 �T M F TEST "oL.Es f�o' � o Q LAG PUMP ON AT ELEVATION • TO B� L>✓_V�l- AND` STA81._.� I C H SYSTEM PROF LE SYS i LEV. 38.0 t W LDVELL.S ROtJD. W USE TWO RS WHR 1 1 HP S IBMERSIB NOT TO SCALE rnE o U LE PUMA s tJOT�. _ p D I (A , OR 'APPROVED EQUAL, RATED TO PUMP 14 3 GPM 15 . 7 SEE SHEET S F'02. TES O �0 @ T_ N LE- DATA. . OF HEAD.H _i CU I Z j N N W , F-- h- U -'--- - W 1 7 -(1 � Q gym cc>L � L� CI S D f• - 1G -0 ' 2-s wNrr� (� a 13-0 Dt L)E Z 0 = 1 ' 12-0 B►.LICROA.lO +,,,-, N V o Z (f� Q a a g j I Ed6ulf FO "GCLOE RL-FLEGTeJE `� Q w D . � o r N J 0 I I I I I SELL' SflCEEL� SY►a�ol_ LFCsEl1 y t o 1 4•_10•• ? Z I + t [Ol-O2 BLUE 4 2ES� I[E TRIaJSPLIPFJ TT 2_6 JI I I ++ O IJI l GAI REO Q Q ss I.J14 T ILLv ..1 � S+ . SILK W i 1 - 7"--0 3 5 DIA r--`- I l , ' ►�: PPO 6 ♦y. ..11� � Q W (:DKNOCKOUTS `^ u.r ' Iu r 18 COVER a 1 - I 6 0 5 DIA. I INLET Q H 10 -o I , L__ h r J x : 1 i OUTLET ( ---- -Z Q W �- 24 DIA. GOVE25 L I I Z _, Q L - - - - - - - - - - - - - - - --� C - - - - - - ►Jo >✓ o C7 - - - - - - - -'= =--� s" T - m 0 Z W - .. 3 W L - \ - - - - - - - - - J -� PLAN VIEW 9. 5 DIA. OUTLETS 7h DLA. INLET HL�vc.w�SETTS TtAFFIC - - -- - - - - - PLAN VIEW. , C I -----I j P.c U- GN►.►J►JEL POS swclti� sc�s_Y ca. .r� S � -6 x 9 COVER ;-18 CIA.COVER 10 14 C.OVEF I „ -4S l.L.cot0 PSIIC D¢n/E, 24 DIA. COVERS 3•• , 1„TAPER+� � / ►10rGVJ>Jt_r_,'1••4i.SS otOcel m 6 LtiALtS R I O PLAN VIEW � , : 7c LI b - � o of ! � 4 L 7� 71 2 6 „ EOc�4L-yc_E 5lGlFG! IoJ9 ei > -1 a Z n; FOGE � �J••.L S. 10 H-20 LOADING 1 i : IA INLET --- - , �i D L r � - .. , 3 t _ T T r . 1 1 8 V-10" e i, c I , I , .. 3 1 3 L . a s , coac. 3 r.. - OUTLET D: f 2 I .� i L 4- y 0 i 4 -6 � ...• : 4 4•- -. i OU D i- I e: t LEVEL .__. ., _ -Z 4 4 f LEVEL I I - - I . W I CROSS SE CTION VIE I - -3 9 _ OUTLET DISTRIBUTION B X I 0 HANDICAP PARKING SI GN �_:1 CROSS SECTION VIEW 7 A N PE I FOOT OF LIQUID , _ CAPACITY 540 G LLO S R NOT TO ' SCALE NOT TO SCA LE LE : 1000 GALLONS " I CAPACITY : : O 7000 GALLONS ' o � o F- Z I Z J I- i W 2 _ W i W TRAP DETAIL - W PUMP CHAMBER DE TAIL GREASE R P - SEPTIC TANK DETAIL A �- w N IL SCALE NOT TO SCALE � NOT TO NOT TO SCALE ; J '^ ' V J i } . r � m _ o Go \ / \� // 1!L mot' / o �/mil P a h- '---WALL OF PUMP CHAMBER ~ Q > , i I , COQC. wEARI1JCa SURFACE 2M�x N C3T � mw -o MI►T 4 I 1 11 A5E covRS� TYP � p t�►J D IZ 8 C) Y Sri -1 B CO 18 LOAM F T -yry r tT rJG. _ � - _ W u _ W I DT>•-i � SLOPE VARY. b,IZE A S I 111 SEE LTc.1 Ca 1 n O BIT, Co1.1 c- 5E2M o >t I Fo12 51_0 !_. SSE I - oLsN1 Fob L_.Aw►� 4 O.S. a Y. Z �- l . C0Q C. PAvI ►J C, -� L , o\u c ' z '. �•T u 11 r, Io .�[./. M. BFZ ILIZE - Cn co /Io w F T GATE VALVE >, to m n- d - a •` Q ZLL. yl \g r. --r. � 4 CHECK VALVE a a a a t- u L _ P cTET� ►JaTNE MATt=2tA L . 1 u a o /� RENIOUE A.LL TOPSOIL- SUBSOIL AND / - - a // it c o, - - 1 C2USHED ST01.1 E o-rHE2 �LI�'TE12toUS MA-C"E2 i_5. /�/_/�/_ COMPACTED G�.AV�L 02 , _ / PUMP PUMP 7/7_ -& 25 o.C . _ A s�oN Jol►.IYs T 1 o C• PRovIpE EXP h1 I L II I ,1 1 S CO tJ C 2.E E CUR-5 Q��T,�I i� C 11,13. O tit C 2.'E.T E, WAL K DET&,I L M nil. M P MIN. BITur� i ►�ou T ►,ioT To SCAT RAMP DETAIL SCHEMATIC VALVELAYOUT - -. L5 k ► OT To HANDICAP NOT TO SCALE NOT TO SCALE ,.. ! , I I + ,+r I s m i use E.L Le3AZ0tJ FOvrJfl221 1-T 103 a MP.QILEfl SEV/EFe �1 1 HOLE IIJ GE IJ T 2 o F GO\IEGZ O fL E-Q .L_ _ 1 C L. ALL GUV E.(Z- u _ Li r- D 15T. BOX Q CO vEQT g 4 = QlM�I - Co5.8� 21M�2 - !0(0.05 = 3D iZIM ELEV- VARIES 21M (o8"f0 RI -GS. O RIM G.(o.3b 21M= (o(o.2U M 7 1 - GOIJGSZETE BLOGY LAID. ._ ' EA Ll 1 nW5IZT TO 8E ItJ FULL BED OF -' 11 U ,. " R 5E�dSAz- p CONCt-�ET� PAL L BLOGK A MOfLTAR �/IT4 t `/2 .. .- 8 f� S Off' y OF PARGETING 8R1CIG. D COU dF R� SeV/�iZ f' r, oUBLE 25E D ON THE OUTSIDE. E l U LL 01= Z Z 8R-lGK S T N A F BED :. •, ,., MOR-TAK- AND O r►.a - ;•. � to ::. .•. _. I. H OUTSIDE. I ..: F02 LL GHIM►� S eY r Z4 24 P(ZE _ C I, „ (0 5D2 3S ": � ,. .. CAST LCACNII\)G SIT BY LO AL o5E1] :.. „ „ ti'. (c' SDQ35 : :: ::: v ,�„ SflTZ 35 RVG. ` 17ISTR1guTOfL 02' 20TOt�1R7 L 50I,1S P.V.G. SEWER 24 24 �.�. . P20P Lo P. SAiv. SEkJE2 1.'�p% flzo - N.SAnJ. s>✓ - •.. : .•. ' . .. ,•.:.,. "�3 cl_R• „, �, .. , 4 64A0 3 CLEA2 3" CL i Z4 04'1 Co2. 14 ZS 5 . 1 . l02 l4 D2 3z.5 �>zC 4 O F �5 - �-Z �aAS%4 ED STONE � �0 4 loo.S - �. 15 � ® -' E Maw : .,: .-.� ...•. .•..... - . ..-. �-:_-;- a: ;. .. . ....-. . �•� .. � 58.50 1 ;: `• _ -7000 CxALLON `^) ld..o0 -; ,. (05.83 Io 3 SM 2 2Etr.1 F02CED CoIJC. .. ., ep . .•^•:... .. ,- .; h SEPT G TALI K ,. s ; , c T 12 PREf�ST LEAGHILI C PIT o e .y 1 /�' Schedule of Inverts DST B - n I 53 - • PACT iI. - 60 . 00 TO 8EInvert into septic tank n c e w> D Invert out of septic tank - 59 . 75 I Invert into pump chamber 59 . 50 S>✓PT G A 7 \c/IDC SCHEDULE OF TILT BULB S TI1GS Invert out of pump chamber 58. 50 , a , . . ' 1 „ O _ STP - _ - _ D 8LE _. 66 .00 O VEL AtJ 4 0 Invert into distri bution box _ T B>✓ LE � : � � SoT-r�c-� ot= Prr - 5�.40 _ INSIDE BOTTOM OF PUMP CHAMBER _ 53 . 20 _ .83 distribution box PUM CN M I✓2- , t of dist _ B Invert out D I ELEVATIOI`N ? . 50 _ 4 LEAD PUMP ON AT 5 its 65. 40 - : leach ing. .into 1 Invert . _�. , 9 P LEAD PUMP OFF AT ELEVATICON 54 . 40 c- Iv LEA HI U PIT I ELE�I. 57.50 R...rJTTOr-t o D� HIGH WATER ALARM ON AT EIGIEVATION 58 . 00 I F TEST' N LES I I Z I t\10 4JATEiz OFhE2VE1]. A PUMP N AT ELEVATION 5 8 . 5 0 o B>✓`- I._.>✓vE-� `A. 5-ra8i�.�LAG U O T ND EL 3 .O YSTEM PROFILE EV 8 V/,�'1-•ESZ LE\/EL. It�1 S W LOVELLS Fb1J17. W I n P - WHR 1 1 HP SUBMERSIBLE PUMPS OTE. _ USE TWO LAYERS 0 N TO SCALE NOT � OR APPROVED' EQUAL, RATED TO PUMP 143 GPM @ 15 . 7 ��EE 5H>✓>✓T 5 FOB T>✓ST HOLE DATA. Q OF HEAD. U Z : I N W F- U y Q W 17 -0" a Z•-6., WNt7� I-- V Z � _ 16 . 0 13, 0.. O- ., >5 e V IJ 12,_0„ .` J '. � 1.1_Wl1�JU►.1 �a ei.,.ilc o.co v W N � a `- c Z SPEC. w J I I j T l ca 3 O << N J J = a _ I J ► 6• 0k- uEC."n R_ Er,L'ED SCREE S`'( � y t "O 4-10 I * 1 COL-OQ BLJE 9 4F_U A[E TKJ.aJSPA4EIJT f" N - I - 1 .. J I 1 1 N1 1 514� lZEO W j y-6 I I I"V_ To eLLU ►J TF- SIr K . I� J U) ' ,w ui YI W W I steeE.J v,eoc�ss. � � N is I I 0.. r I KNOCKOUTS „ I 18"COVER V/ T Q _ ., � INLET 0 _ f I I 6 0 5 DIA.- r h 1 r X Q W 14- 110'-0" , OUTLET I _ L L - - - - LL - -- J -- ---- 1 0 c e 1 I I Of G ttl V Z 24" DIA.. covt-'2s "I "? 0 C Q 9 -0 I ►JO7E 0 m - - - - l L - - - - - - - - - - - - - - --J �1L8-� O Z Slc,�l i C ►1.lCL B( Q W W -- - - PLAN VIEW 9, 5" DIA. OUTLETS 7h"DIA. INLET: NASY.[WE,ET7S Tc�.r��C � - Q �- - - - - - - - - - - - - - - - - - - - - PLAN VIEW U- CN.1.►JUEL. POST a , -6 x9 COVER r-18 DIA:COVER 10 . 14 COVER 3„ M • ►�G4:1/F_1-L t•�ArSS 02 W IA. COVERS �,a FI.11 Eo G E 24 D "WALLS 8 1 TAPER 6 � y -Trt_ L17' t71' 5260 OC PLAN VIEW C +r 4 - � J. •�- .•._ E4 GIr.ICI•-TIoJB I -1 a i 10 H-20 LOADING v N I i v e IA. INLET .. .. . . r : _ , T i I I ' 5--4 s CJa1G. 1 G DIA. , I ►:. P � _ e 3 2 , - OUTL ET Gr, O 0 .►. LIQUID I U D LEVI EL 3 9 2 4 , I 6 _6 ,r e _ .- .� _ LIQUID 7 6 - -. .a. .. � �. .. 1.7 4 , i 12p � LE _._- - II -- 1 6 I N VIEW CROSS SECTION I - I X HAND PARKING I I 3 9 OUTLET DISTRIBUTION BOX _ HANDICAP SIGN CROSS SECTION VIEW a FOOT OF LIQU ID 540 .GALLONS. PER I 00 CAPACITYSCALE T - - - - - - OT TO SCALE NO TO I J • LL CAPACITY • 1000 GALLONS Q 0 1- 7000 GALLONS S Z J W Z - W � W 2 PUMP CHAMBER DETAIL GREASE TRAP DETAIL _ .9 TIC TANK DETAIL w SEPTIC t ,. Q E NOT TO SCALE NOT. . . TO SC ALE NOT TO SCALE W t � - I � m OD 4 , I . II` a � lilLij I WALL OF PUMP CHAMBER a 0 Q > m W 2 MAY. 131T. Co1.1C• WEAR.IIJG 5 U2FACE : p � r 1 I_ 0 Y I ASE coURS� �P� w FO 1z. PLAt.I ILIG W _ A Z f� LO M L / r I S tT_ COtJG. VARY A Q U W 1 DTN SLOP E 1LIZE S i.lil SEE t7�./Li 1 , 411 O.S. & Yr Z III P BIT CO+,1C, BERM Fog SLO E St`E 01.7 C.. PAS/I t._I G � LOA.M F otZ LAW �- BIT. c N I GATE VALVE 5 D\u c, 2 Co 10/1 o vJ.u/. M. F E SR T i L Z I m p. 1 - •� a u; Q z V- - i _ � �_...'-.,= ' -�.'� =� /r •�i // Q � 4 CHECK VALVE a a \9 cj -1 F U �' IA O 8 - ILL GVMPACT-E� NA-nvE MAT>=1zla.�. \ Q A - / I O Q•LL TOPI�OII- SUBSOIL ND 8 11 2>✓c�l V>= C2USHED STo►JE - 1 PAC ED G�w>✓L 02 it CT-HEL �L�TE2lous MP-c��zcA>✓5. ///_/�/; _ COM T PUMP PUMP SON J O I LITS A`r 25 _.o. C. ov E EX PA L1 I 1 II I 2 I, O C P2 I D m C DETa.t lr ?AIAF MIN, u � �oUs co►�� BETE C � � T C O I`1 �. BIT N( o To scams E ti T ; .. HANDICAP RAMP DETAIL SCHEMATIC VALVE LAYOUT TTO Uo _ T ALE SCALE NO TO SC NOT TO r r E-A-c-"I C- V>1 P 'C,a qrrp� 5 rvnbvq ­4 i2s -7 -L CS /,V _ao, W16 (CO PF'F-=?--) co OTIS C. NICKERSON ET AL 0 V, V�- -(U/6) \D awding '41 jo 76 NNI 40 P VL 0 P, C_ E N 610 05 2 I "j y 5 _7, L I / 585.00 C A" 6 t�lz I I I Pit `X I, 4K Ct C, -74 TYF'F--' r--) H -N fA,t� rL 0 S z4) Mills j e'L.. 4 *", -- 11�1: r C_ P LhJ TO S (z..I'L MAI L-1 W I_T Al. t0el_ �L cz­t� -T Q_x�-P C�L I n_ ra r& �,4 so I c:,<�, A� 3. G-7- TZ 6. -1-1 _1 C.S. 3c� cgs D w16 6e_0PR-_-q_) C_ja;'t e, -0 63 TZ I-ii-� -7 C5 0 I.Gico ly L) ROBERT F HAYDEN IV z L _7 Pond CC �j tj LTI .0 0 Ct) > LLJ % C, -K 7 Q, (z_ ja3*- Flat PU rig AA- I-_:_ ...': 6 CIA '�3 1 1-- U Al C_ CS (_,eC3 -­/P C_ 1 T T- U,1/11 Q.,Q, /V_ TZ I'in 0­11 (09 /r X0 "R L E W, J�j < rj P, ON < 0% 1 1 0 CrD Fox .0 A \",�4(3 > Uj I "o r Pine 6. OD c o ki LOCUS MAP Le S G-7)e�i� Q P_ I L 0 5 _,C�s S C A L E 1 2000' (\j 0 V-0p I-L P,L) U') 19 -T--, V4OtMAE JZ6 -to C\j 12-, 1 G "A--(�J 9AQSL_ /Aq, > 0 F_ C) 45, "Z3�NT (/) 30 C- E, 1� it-eli- (f) rype 5, LEGEND I A!, 7 0 Vol .01 w OD (D C:) -r,-? kz�Z�l i2,, < 1,,4 100 EXISTING CONTOUR j P_ -7, Hot-1pr sz I Q MA 11 0 dix C J-L- 97x5 EXISTING SPOT GRADE TyFsa U -7 P C�,2" J 4,-7 c�)cD 100 z I --A 7X PROPOSED CONTOUR V 4'\ 5*s C/_ d L/ 97x5 7 PROPOSED SPOT GRADE 1A W P C2,Z2 t-) G_ c- TEST HOLE NUMBER AND LOCATION U L,�J_ �C� li", 0 __t I < w -,A ;�, -T ot 1" 0 G3 4_� 0 PERCOLATION TEST HOLE AND LOCATION Z F- 4.-7 0 0 NN 0 L r 0) C.B. SMH tA U 111 0 0 LL, -T- A SEWER MANHOLE -—-------- 1 .1.1 (1) 4( > AP Lo a _j > < I 'V z %-.I' C/ 1��/ CB CATCHBASIN Tyvr-: "ia;, X r\ X Top or :D -71 A7 _j 0 G7 (�94 L SAN. PIT t It '9 1-, _Ar,4� S SANITARY SEWER DISPOSAL PIT t% z .9 M NDUSTF 0 1 Iq P­ \ qli� 0 y �OAD 1 5,14 AREA TO BE STRIPED < < w go G4 ' V ( PR I L�TE n QDI) U) > Z) B.C. (n U) ; J 60('-31 22 E C. BITUMINOUS CONCRETE CURB la- z < w I it rD w 109.01 P.C. C. PORTLAND CEMENT CONCRETE Z TYFr-- '5" �I -7 < CD 130.00 C01 V=�* ECK 0. 0 z LL w \< OPPE2) 71 24-30 '14, (U16) J( I-V t'4V IT C_L S-L 4z 76.00 EED P_ _30 1 t--�-7C:) E4 cc-7. P" ­1 C0 00 -7 Hc"E Ii TO C\j L MALIN) VAtJE�_ (51 13 1­0 FLA,- TX-) TYPE ,x F -T�-%L CONSTRUCTION NOTES z Z 7 I-E�_ 7: S c. REFER To THE APCHTECTURAL PLANS FOR EXACT BUILDING DD\�FNSIONS. .2 8 w/4 �-r,6 L,2 0 -r 2. T, REFER To THE PLUMBING PLANS FOR THE EXACT LOCATION AQ0 SIZE OF SEWER 7YP� -3 TAL !S/-'.1,4 , ip 7 t� AND kTER SERVICES. �-_N _P.T tt Al tn- 1(0 - 3- _L_ P_ THE SANITARY SEWER SERVICES FROM THE BUILDING TO THE 611 PVC SEWER ARE Schedule -of Inverts TO BE EITHER CAST IRON OR SCHEDULE 40 PVC. 4. THE 3" CL 125, SDR 32.5 PVC FORCE AIN IS TO BE LAID WITH A'MINIMUM OF Invert into septic tank 60. 00 4' OF COVER. IT IS NOT To rz BE CONSTRUCTED WITH ANY LOW POINTS ALONG ITS 4 4-'yci Invert out of septic tank 59 . 75 LENGTH ALM AT NO SMALIR HORI-ONTAL RADIUS THAI,, 9 0 P _L Invert into pump chamber 59 . 50 5. THE 24 HOURS PRIOR To THE STAR-, OF CONSTRUCTION OF THE SANITARY S "�R 91 _j Invert out of pump chamber 58. 50 ENGINEER AND R NSTABLE BOARD OF HEALTH, 775-1120, To OT IS BE N IFIED TYF)E:%%Igf t4 0 Invert into distribution box 66 . 00 LIVER OR 11� X �K, Invert out of 'distribution b SEPTIC SYST01. 7c), 7LO Lc,, ox 65. 83 S 10 6. THE WAL SUBMERSIBLE PUMPS LjOCATED IN THE PUMP CHAMBER 6 (CqPPE=_V_ Invert into leaching pits 65.40 CD G5 ' jo 'S ARE To HAVE (\j IT (U/6-1) n4 I AUD _11S AND ELAPSED TIME METERS WIRED T�LE AND VISUAL ALARI < S14 cofoc>o rr(U/6) BACK TO THE Lo C)yz -2 \a1<5j OFFI(.M.OF THE SUPERMARKIil. j '7 �c 0 9 P C0. N 7. RI CL LL. 'STRUC -CONTRACTOR IS TO-LW-ATE �MAP --AND,--:* 0 P k -BULB 'SETTINGS P START OF COIN -in M GG , P )< SCHEDULE OF TILT PR K XISTI14G SEPTIC SYS=_ ON THE NORTHERLY SIDE OF TH" Q-, BUTTfNG. E EXISTING D z INSIDE BOTTOM OF PUMP CHAMBEA 53 . 20 0) P I LEAD PUMP ON AT ELEVATION 5��5400 8. THE MANHOLES ON' THE GREASE TRAP, S C) EI"IC TANK, PUMP C1La21BER LEACHING PITS Q<:1 AND DISTRIBUTION Box ARE TO BE BROUGHT UP TO PROT-30SED FINISHED GRADE AS /0,39 LEAD PUMP -OFF AT ELEVATION iz, Tz SHCW ON THE' DETAIL SHEET, HIGH WATER ALRM ON AT ELEVATION 58 . 00 6 �Jiq -TOP &LDG. 0 1 1 — F 7 D LAG PUMP ON ATELEVATION 5�. 50- 9. ALL PRECAST CONCRETE UNITS USED IN THE SEPTIC SYSTEM Ap a) 3� /\D FOR P-20 LOADI1,4G. E To BE DESIGNED _777ct (0 USE TWO' "MYERS WHR-10" 1 HP SUBMERSIBLE PU PS\ -10, ALL dOMPONENTs OF THE SEPTIC SYSTEM ARE TO BE SUPPLIED AS SPECIFIED UNLESS 05 PRIOR APPROVAL OF "EQUALS" IS CBTAINEDFROm THE ENGINEERANDBOARD OF HEALTH. 7 OR APPROVED EQUAL, RATED TO PUMP 143 GPM @ 5. 7�'LEON4RD W d 26.46 OF HEAD. p 11, TEE EXISTING 1211 CL 52 DUCTILE IRON WATER W &9 _ ECK TO THE SITE MAIN IN INDUSTRY ROAD IS To EX=M 0 o APPROXIMATELY 920 i�,Ehj, AND INSTALLED ON THE SITE AS SHC�,7N ON THE SITE PLANS. )� w TWO FIRE HYDRANT ASSEMBLIES ARE To BE CD . 6�) INSTALLED ALONG AdoU INDUSTRY ROAD PRIOR TIO REACHI14G THE SITE. TUE LOCATION 32 '_0 7,, is TO OF THESE HYDRANTS - 10P 13E COORDINATED WITH THE WATER DEPT. AND FIRE CHIEF. 0 �a U ROA n 12, THE z BUILJDING IS TO BE FULLY SPRINKLED. 0 THE CO14`TRACTOR IS RESPONSIBLE FOR OBTAINING 7-iM SIZE AND LOCATION OF ANDPOST INDICA- SPRINKLER CONNECTIONS, FIRE CONNECTIONS S_rA TE 6,34 -7 -,OR VALVES FROM THE N=HANICAL PLANS AM INSTALLING THEM 0 AS RIDOUIRED. A P11GHW -46 lal z _j 13, ALL BINDs, 9-t: 1 3: 6 pLUGS_HYDR10rS, ETC_ ARETO BE ANCHOREDIN PLACE USING 0 THREADED TIE RODS, ALL WATER INS`1ALJ_ATION IS TO MEETI THE TOM OF BARNSTABLE 220 -1 Cc> WATTR' DEPAR7711ENTI SPECIFICATIONS AND IS TO BE INSPECTED AND APPROVED BY THE LOT 2 WATER DEPT., 428-6691, 66 0 14. THE PROPOS - ED WAIPER MAIN IS TO BE INSTALLED A MINIMUM OF 10 F R014ANY OF THE UNITS IN ITIE �ASTEWATER COLLECTION SYSTEM. AREA 7. 547 ACRES "Sq'e 7t ,29. 88.00 i5, ALL ELEVATIONS SHON7,7 ON THIS PLAN ARE BASED ON NnM S 99 FA LEVEL DA=. 4zeg_,S k, i 8-.4,5 16 . ONLY WASTEWATER, FROM THE BAKERY AND FOOD PREPARATION AREAS OF THE SUPERMARKET ARE TO BE DIRECTED THROUGH THE GREASE TRAP. ALL TOILET WASTES ARE TO BE DIRECTED TO THE SEWAGE.' COLLECTION SYSTEM IN SEPARATE PLUMBING. L -7 y ra rry,w, L- C- QS -rl-/P iL �d ";, 'ranbvrz C C-,-7 -Z-C�, (p 1. 4.,i CID OTIS C. NICKERSON ET AL r(U/ V- 6011 6) o 4n 11? �7 N 6 1 0- 5,2 2 5� E 585.00 B Y' MARSI� Z, j L 7x 5 T'� Ct C G-7 "o 1-4 L /w ar) izut-j k-", VSJ TV `D MAI t0el­ PATjg, 12- I:S� it� (-4.Sol lf�I.- -T 4 6r C-,-a 0 �z \— = ---,.S(--.) I �� I - "y "I - V 181, C- BogS ?o 'N G-7— > m k� �74' rz -T 1-/P LF-- C,LC)A 0 c�-4 o L 61 s,s o ROBERT. F HA,YDEN I V P-\ -- 2. -1-R, Gs ILL j Pond cc (,j o-CD 38 I_x > A 7idal Flat Pu ;L CD (S :2 ,1- I'v U ti /100 Z I- % p /r Fj — 1 'R I\T (09 - G zno L�''4. I V-3 zz /G I s 0 40 '/A7 0 'A <Ej> _A 4� L E 01 < \j C'> 4 \Z;�, I,-A) ON \ 0, F4o x rj Ai C.- SO r UJ 0 Pine C- 01 00 ZI T—:Z14 11 � I — -7-/ P 1;-7 C-` rTl— C­ C, LOCUS MAP &0 t �-n le -71 W 00 LA SC A L E : 1 2000' C, 0 rl- Q 0) In ...... ---It P I ole" H 01!4 FS ev*0 To Q S J 0 C- -r--1 PRI C- 31 M) 140 IL > Q) LEGEND or L-)k;w 71k `4 7� -T\1 91- 0 CTI w C>C) I . I r,>e> 00 -e, C)CD -y Y 100 EXISTING CONTOUR �,A P_ rn -7 0 it-\ Cj AN,10 \9 o, \.9 9 J 7- 97x5 EXISTING SPOT GRADE E—� Az:.c-I-A & U 2> 6� k I-n -7 CD 2 100 z PROPOSED CONTOUR 17 tt/I *V 4" y- P kcE-"e> 97x5 V1 7 PROPOSED SPOT GRADE (A it (. �Q > 6 V/6 �20 ppelz) C/ 42- W I­ U TEST HOLE NUMBER AND LOCATION In -- (�-7, 1() 1 L 0 -T'y w -2 Iv, I 1:D 6% q,P "I -,j, - -7 c) (0 0 PERCOLATION TEST H U - OLE AND LOCATION 0 iz 0 X GO L Qm va, (7 CH 0 "A SMH U A SEWER MANHOLE AP \N1;.1 0 \9 w r) 0 �,, > %-..- G le k-17 z 1% il (I �1�1/ CB C)v P 0H fZL4,j-ra CATCHBASIN C0 < Uj (,7 4 -71 x7 1--� SAr-i- Rcr S A SAN. PIT —J 0 ti SANITARY SEWER DISPOSAL PILT Im Pq Z PI-1 '9 NDUST Y �OAD j -9 z sc> vl�, = 1 ��514 7�,� ARE ' < < E A TO BE STRIPED w PRI AT 0 > G4 V 5 C�l D.C. �C. & 5 C/) BITUMINOUS CONCRETE CURB U) U) 0 600-31 22 E I w 3 z < 7L 14 L F-� re � ­. D.C. C. 0 v 1109.01 w V \19 7'1� 13" � e - - 'I - PORTLAND CEMENT CONCRETE 0 4- -7 oA Z Rz .30.0 < VW�T. 0 0 0) 0 z L w CB IX -\:) i _,- ��> "44-30 C:) c_-r P�'L 0 P. I-L, ZI/ C:)(D �O�JkDu I 4K I (U16) C.L '7,9.00_3 6 ,C:)o -L I 1 -1 )� --A 0 p Cl) 0 C) CONST�RU�TION N CID Hot-AE-= L) TO- -rypE ;N� (f:> C\j MAINJ 9AOeL- (11 140 lZur, To 0, ti t"I c> L tA FNtj 7 �-A III z REF z ZR To THE AR=CTURAL PLANS FOR EXACT BUILDING DIMFNSIONS. am�i ;6 2. REF 'ND -4/4! j To THE PLUMBING PLANS FOR THE EXACT LOCATION AQDSIZE OF SHIER 0 AND SERVICES. Typ� -9 ( 7 �Sc­1,4 7 t' 3. T=HE ITARY SEWER SERVICES C),-7 TO FROM THE BUILDING TO r1iHE 6 11 PVC SHJER ARE t�4,v �(- c-� EITHER CAST RON ORSCHEDULE 40 PVC. Schedule -of Inverts A 4- THE CL 125, SDR 32.5 Pvc F0 C- RCE MAIN IS TO BE LAID WITH A 'MINIMUM OF 'S P- Invert into septic tank 60. 00 4 COVER. IT IS NOT To BE CONSTRUCTED WITH ANY LOW POINTS ALONG 4� rz '' Invert out of septic tank J-A-ND AT ,N0­SMALL;-,R-z0jaj --go TS ­,0NTAj,,-- P p chamber 59 . 5 �61SINEER AND c- Invert into pum � 0 5 70-/ BARNSTABLE BOARD OF Invert out of pump chamber 58. 50 HEALTH, 775-1120, is To BE NOTIFIED 4 4JRS PRIOR To THE STAR'-- OF CONSTRUCTION OF THE SANITARY SEWER OR t-4 0 Invert into distribution box 66 . 00 SEPT C SYST01. Invert out of 'distribution b LLJ L x,, ox 65 . 83 C- 'bUAL SUBMERSIBLEPU�,TSLOCATED IN THE PUMP CjWv1BERS Invert into leaching pits z 65. 40 OD ARE TO HAVE U17- (U/,�-.) 10 G5 ?- *8 \&J/C--T U AUDfBLE AND A C\j Evk w C) VISUAL ALARMS AND EL7UPSED TIME ME WI P, O.FFI(-"h- OF THE SUPERMARKETI. RED BACK TO THE 14 corjibo (U/6) ,_,/ III - I LO L (Z)YZ 8 \A//6 C) j U- -7 1?-) co C\j 7. PRfOR To THE START OF CONSTRUC-i 0 1014 THE CONTRACTOR IS TO LOCATE, MARKAND of )� SCHEDULE OF TILT BULB SETTING�/ PRdMCT THE EXISTING SEPTIC P, I . /41=1) N N BUf SYSTEM ON THE NORTHERLY SIDE OF THE EXISTING LDING, . III z -31 INSIDE BOTTOM OF PUMP CHAMBEA 53 . 20 co 6)(/S 8. > X T LEAD PU M MANHOLES ON THE GREASE TRAP, SEPTIC TANK, PUMP CHAMBER LEACHING PITS MP ON ATELEVATION 5��5400 C- V?" zt:, - 0�, I(�, - ­� Q�Q 0 P LEAD PUMP 'OFF AT ELEVATION AND PISTRI13UTION BOX ARE TO BE BROUGHT UP To pR01 POSED FINISHED GR 'ADE AS c--:i C) c�o TZ HIGH WATER ALRM ON AT ELEVATION 58 . 00 SHM ON T[E� DETAIL SHEET. 10,39 LAG PUMP ON AT ELEVATION 5C5 - 9. AU PRECAST CONCRETE - 06 " W * c>P c�;,7 1' 7 cy-�, DG. P 7 /\D UNITS USED IN THE SEPTIC SyST A To BE DESIG 0) FOR H-20 LOADII;G. EM RE NED WO 10, (0 -7c USE T OMYERS WHR-10" 1 HP SUBMERSIBLE PU P CO"PO'1:NTS OF THE SEPTIC ,SYSTIM ARE TO BE SUPPLIED AS SPECIFIED UNLESS S 7 OR APPROVED EQUAL, RATED TO PUMP 143 GPM @ 5. PtOR APPROVAL OF "EQUALS" IS OBTAINED FROM THE ENGINEER AM BOARD OF HEALTH. 4K L EON4 7� RD p OF HEAD. 326..4 -11, TI-P EXISTING 12" CL 52 DUCTILE IRON WATER MA —N, Ui W ECK THE SITE _IN ININDUSTRy ROAD IS To EXTEND -7 APPROXIMA'IMY 920 FEET, AIM I14STALLED ON THE SITE AS SHOWN THE SITE PLANS. w ri"WO FIRE HYDRANT ASSEMBLIES ARE To BE INSTALLED ALONG CD 0 r IMUSTRY ROAD PRIOR To REACHING THE FALA40U-rjq 172 1 0 C� -32 SITE. T11E LOCATION OF THESE i I� To BE' COORDINATED WITH THE WATER DEPT. AM FIRE CHIEF. HYDRT�WS 9 07 ILI 0 VD 0 U RoA n r% 12, + � BUILDING IS TO BE FUILYSPRINKLED. THE C014,IRACTOR IS PONS z K) 0 RES IDLE FOR N-1 jz. DBTA.R.M�G THE SIZE AND LOCATION OF SPRINKLER CONNECTIONS, FIRE T CONNECTIONS , C- S X 0D POST INDICA-LOR VALVES FROM TTM MECHANICAL PLANS AND S-rA T 6 AS REQUIRED. INSTALL_TNG TTD�14 '3 ;-';6 < GHWAY z 13, 3. Ci ALL BENDS" ZESI PLUGS, HYDRANTS, ETIC. ARE TO BE- ANCHORED IN PLACE USING 12 T PO- 20.00 R�READED IE RODS� ALL WATER INS`7-ALJATION IS TO MEET THE qCWN OF BAR C) \NSTABLE KRTER, DEPART=- SPECIFICATIONS AND IS TO BE INSPECTED AND APPROVED By THE 0 NZ W1,TER DEPT. , 428�,6691, RO(J R::,30 00 LOT 14. br THE PROPOSED WA"ER MAIN IS TO BE INSTALLED A MINIMUM OF 10' FRO14 My OF THE UNITS IN THE T�TAS-jL7ArATER COLIMTION SYSTEM. AREA . = 7. 547 ACRES VjkZIt1-j<2; Gvz-e 88.00 Tz 29. 15, ALL �L�TIOI�S SHONW ON THIS PLAN ARE BASED ON MEAN SEA LEVEL DATUM. 99 4 89-�8 16 . ONLY �IASTEWATER, FROM THE BAKERY AND FOOD PREPARATION AREAS OF THE V SUPERMARKET ARE TO BE DIRECTED THROUGH THE GREASE TRAP ALL TOILET WASTES ��ARE TO BE DIRECTED TO THE SEWAGE:' COLLECT!ON SYSTEM IN SEPARATE PLUMBING. "ran -:�Z11 -J I ZENON WASTEWATER TREATMENT FACILITY ANODIC TANK EQUAUZAIiON TANKS AERATION TANKS BOLDING I= 611 TANK Is 63,19 AERATO TANK) =53.63' +�� I 61.59' OU TRANSFORMER PAD DARGENCY GENERATOR PAD 8' ` DOSING M STATION A' 8' PVC CLEANWT � R= 64.92' ,I Is 80. SETTLING TANK d r S O Is 61.59' (OUT) I= 8212' BOTTOM= 48.91' 7.71 SMH-14 SMH-14 R- 63.94' 8�8 CHAMBER VALVE CHA Is 54.25 SMH-13 / BORN Its 64.04' _ Is 54.20' W In 51O (DOSING) = a,92' LS-1 I■ 53.35 OU 6 ,.-- 5 6'�6 5 f REMOVE R= 85Or BOTTOM. 5264' 6'=64.90 I SI �; / SEPTIC TANK Is 53.18' S1 1-14 44=65.06 �1A00 GAL. u' S _ �n ui GREASE 0 I 53.30' BUx) �, S i I■ 6352' OU 1,000 GAL BOTTOM- 7. GREASE TRAP R=65,31'4'=61.00' NOT FOUND) 6"=60.54' VJ a, N U U NZ a � �,; 0 °C R o ks , I'- Q 7,000 GAL SS ..-.. r/1 SEPTIC TANK l �. S v.�/ TANK INVERT=60.00' �' haw , w D-- o 0 l�� LIM P CHAMBER O � INVERT=59.50' C:p i SMH-13 ,Q R=63.55 ,�w - 58.00 58.03 57.99 58.03 58.02 57.95 D I= 55.4r BLDc , �o� WIDE) �0A In 55.46' I' S540' OU 3 GT a1/a6 57.97 I=5 I 57.97x SMH-2 �t�/ 112"x12"TSV ` ''( P(���ATE 40 6"S 1■59.47' 60 x72 x 57.96 57.96 o R-7t.5t us'TRY 58.04 R 89.82 �� SMH-1 GT-1 LEACHING I 60'x72' I= 86.4S FM) = ND V I=66.30 EX R=8383'83.81'838r FIELD A LEACHING I= 66.13' SMH-1) / I=66.25 OUT Is 6"GW I■58.58' I=56.5' I■ 5&42' W 57.98 57,98 x 58.03 57.97 x FIELD Y i J Qo / 189.91 5Z95 B 57.99 4" VENT R=68.66'( g 1 IN-66.00' Is 86. TURN TO ROOF VENT 58.02 57.95 58.02 58.02 58.02 58.04 QU7=65.83" 66.73' TURN-ON _ VENT BOTTOM OF STONE=58' BOTTOM OF STONE=58' Q gs MH-2 1' S l POSSIB F - SM 1 I ._ - _ - - - - - I � LJ.I NPV Box DISTRIBUTION MH 71.41' _ 0 Q ' 1 ' ` I 66 r � 87.08' (IN) y L RESERVE 0 L1.I _ 1 ;4'S 60 x72 LEACHING 1 NG AREA ^' I' RESERVE I I I [L = ff LEACHING AREA I I I M❑ / SMH I = IR y R 71.Ot I=61 EX 4 __, y A PROXIMATE LOCATIONS I=66.50 8"OU .__�._.._-._� � OF PI SANITARY PITS (TYPICAL)L) 1 �' TIGHT TANK � _ i R 69.37' / i Is 66.19' (BLOC) SMH-12 $ SMH-11A g SMH-11 $ 5 R=69.03' _ aTg' +-- Sill Ir s s / .58' SMH-3 8" STUB R=70.70' - RETAIL E 65 38' sM T .a, AI L 64 B SMH-11 SMH-10 \ I= 65.33' (STUB) PROPOSED R=68.45' APPROXIMATE LOCATIO OF RETAIL D = R■69.1r SANITARY PIT AND SE I=85 22' (OUT) HOLE i Is 6270' � Is 64.73' BLDG) L.USMH-12 1=83.26' BLDG uJ Is 63.97 SMH-3) I Qs-}4 cl R=64.43' In 6270' OU 1=63.91' (OUT) ��. 8" STUB I= 58.6S SMH-11A) SMH-11A R=69.55'�.� i■ 58.60' (STUB) R= 6689' OD =56 59 Is -11 GG G 60.48' SMH Is 60.28' W SMH-10 SMH BICYCLE R=7a61' RETAIL, .; SHELTER -----` BLDG) (aorroM ROUTE 28 (FALMOUTH RO AD) A D (PUBLIC _ VARIABLE WIDTH�I ) S ! . o (SHLO of 1931 ) DATE DESCRIPTION jDrawn hecked R E V I S 1 0 N S i A BUILT F OTUIT LANDING S BU PLAN 0 C L i WASTEWATER TREATMENT AND COLLECTION FACILITY AT w l SUPER STOP & SHOP BOLD INFORMATION LOCATED BY ON- _ _ _. - W HOLMES AND McGRATH,IINC. MAY. 2002.BY I N 59.49 59.51 59.46 i 159.49 59.51 59,58 cw GREYED INFORMATION IS AS PROVIDED C O TU I T B A R N S TA B L E MA 5s.53 I 59so I BY VANASSE HANGEN BRUSTUN. INC. AND 59.43 60'x72' x 5s.41 ss.37 LJIWRENCE LYNCH CORP. I 59.48 x SCALE: 1"=40' DATE: DUNE 26 2002 I LEACHING I I LEACHING I w ��k I FIELD A 59.39 x 59.46 +59.60 x FIELD 59.39 yr , .., <r � h of m es and m cg ra th Inc. 59.54 I 59.59 B I �...., Civil engineers and land surveyors 59.451 59.62 59.60 I i 59.70 59.67 59.49( CL 0 200 main street 508 548-3564(PHONE k- - - - -�- - - - - - - - -►�- - - - - 40 0 40 80 'a-� falmouth, ma. 02540 �508) 548-9672 (F ) �? o.22 DETAIL SCALE IN FEET DRAWN: MES CHECKED: TOP OF PEASTONE L\LAWRENCELYNCI-I\LL-201409AB\AsBuilt.dwg JOB NO: 201409 DWG. NO: 80-4- 3 E OF 1 (PLAN = 59.58') l N R_67.71 fb a REMOVE ti / SEPTIC TANK N / S 1,000 GAL R=65.31' GREASE TRAP 4'-61.00' NOT FOUND) 6`-60.54' rnt 7,0o N R GAL. / �VQS�S SEPTIC Pi1C TANK R=65.3'f TANK INVERT=60.00' 1 UMP CHAMBER R=65.6't INVERT=59.50' D AD SMH-2 12'x12'"TSV Cpm\jPJE — 40 wiOE� RO R= 69^82' / SMH-1 ND�G+'rRY 1= 66.43' (FM) �' R=7'.5t �77 1= 66.13' (SMH-1) I=66.30 EX = 66 T / I=66.25 OUT }/ SMH R=68.3't Qom° R= 69.91' R=68.66'l S IN=66.00' � �/ / 1= 66.77" (TURN-OFF) our=65.83' 1= 66.73' TURN-ON POSSIBLE_ _ NPV DISTRIBUTION MH =71.41" `BOX P 1.08' . - 67.06' (IN) I 66 8T OUT au �1 4^S NPVJ N PROXIMATE LOCATIONS OF SANITARY PITS 1 TIGH T TANK (TYPICAL) R= 69.37' / SS 1= 66.19' (BLDG) R=69.03 IF-, ~ S _ g8 SMH-3 8" STUB R 65 38' (SMH-2) RETAIL B SMH-10 \ APPROXIMATE LOCATIO pF I= 65.33' (STUB) R=69.17' SANITARY PIT AND SE 1=65. � HOLE 22" OUT 1= 64.73' (BLDG) �— 1= 63.97' (SMH-3) \QS-}4 CI 1=63.91' OUT R=69.55'�s� SMH R=70.81' 1= s7.23' (OUT) RETAIL C (BLDG) (BOTTOM) 'UBLIC - VARIABLE WID TH) S O (SHLO OF 19-51 ) DATE DESCRIPTION IlDrawnlCheicke, R E V I S 1 0 N S AS BUILT PLAN OF COTUIT LANDING WASTEWATER TREATMENT AND COLLECTION FACILITY AT W NOTE: OCATcD BY ON— SUPER STOP & SHOP BOLD INFORMATION L Z THE—GROUND INSTRUMENT SURVEY BY IN HOLMES AND McGRATH, INC. MAY, 2002. LEI GREYED INFORMATION IS /,S PROVIDED COTUIT BARNSTABLE MA Q � BY VANASSE HANGEN BRUSTLIN, INC. AND LAWRENCE LYNCH CORP. SCALE: 1 "=40' --T—DATE: JUNE 3, 2002 LEI <r� holmes and mcgrath, inc. civil engineers and land surveyors 0 200 main street �508� 548-3564 (PHONE) 40 80 10- Lr) falmouth, ma. 02540 508 548-9672 (FAX) ET DRAWN: IVIES CHECKED: L\LAWRENCELYNCH\LL-201409AB\AsBuilt.dwg JOB NO: 201409 DWG. NO: 80-4-13 SHEET 1 OF 1 REMOVE EXISTING 10" PLUG AND CONNECT EXISTING 10" WATER MAIN TO NEW 12" WATER MAIN o �-. -- 1 ! 12"X8"X12" TEE milif `• Vanasse Hangen Brustlin, Inc. / Transportation r T 7O i Land Development Environmental Services 1,34 / 1 `��� „CAs 1C"GAs - - - INCLUDED IN THIS C:ONTRAC J� ��-R -T 101 Walnut Street,P.O.Box 9151 f - WG-- --- - - -W 12"w f Watertown,Massachusetts 02471 / -- -- w __� _ 617 9241770•FAX 617 924 2286 j � � Y 1 _ - _ ~ _. U - 0 12""X10" INCREASER 1 - 12'" GV ON E � � i CENTERMLLE-OSTERVILLE SIDE f INCLUDED IN THIS CONTRACT i s r� � I REMOVE EXISTING 8"" PLUG A1JD CONNECT EXISTING 8"" WATER ! j ���' • MAIN TO NEW 12"" WATER MAIN � if r R p 0T � l/Q,A O / C rJ �''J fir GF 1. I r ! FES-31 } DMH-23 s� I=48.30 OUT R=60.9 T APROXIMATE LIMIT OF WORK TO BE PERFORMED - I=57.70 CB-19) I=57.70 (OU UNDER A SEPARATE WASTEWATER TREATMENT DMH-24 FACILITY CONTRACT 1 R=61.8 I (SEE REFERENCE DRAWING C-16) / - I=57.10 (BLDG) •-•--•- •-• ----•-•-• •-•--••- I-56.90 (DMH-2�) .-•.. •-- -• LS-1 __ I=56.90 (OUT) I __-'.•,•_,__..-•--•-•--•-•-•--•-•--•-•--•-- -•-•--•-•-.... _ � _ 64.1 MAINTAIN AND PROTECT 2 2" PVC F 5540I(SMH 9) EXISTING WATER AND �' ._-•_' --. ••• RCE MAINS ZENON WASTEWATER GA VICES ) � �I=54.30'I(SMH-14) ,2"w _ _ _ TREATMENT FACILITY 10' DEEP s SERVICES (TYP. _22,000 GAL- EQUALIZATION UNDERGROUND TREATMENT TANK / 10 LEACHING CHAMBERS ._. �-12"D • '-.•.:--_TANK & PUMP STATION GE CALLO = R� -' '- '-- GENER-A>T D ENCLOSURE R ss:ot 8" DIA. 3p"O --' R-68 5 I = 61.30 SC-4 -• UGE/T / VAULT SHALLOW ! _- _ _---.- 6- '••. TRANSFOR'`ER PAD -'" --�"'�i' I 51.30 BO M .-- I 65.50 OUT) a , O -_ - IaL SMH-8 CB-20 f » .; �• - ' PR StN R=s8.5 _ DMH-34 _ .> ESSItI�E``�O R 67.3 i � DMH 33 ..r _77 U - - - _ x , L STATION WITH PUMPS , 57. SM, 7 i R 688 �. dY aMh _ N I- �`'�-. _ _ - _ I-63.80 DIaH 3.. c _ .- R I 56.90 OU _ LD _ � F.: _ Ci ^ _ I 65.20> CB 21 �i _ DCB 28 _ I-57.50 UGE/T - _ _ _ I=56.40 sMH-8 I 0c( ') FF. � R-62.9 / CA �H BA I ' ;„, ���.•,,_- ..>..,,,.�._. n_�v p►-iW-° �� x /r %' t ® - - _ , L=56.30(OUT) I=6430 -OUT t „ S h _^ -• c /f LD 1 'ti - 64 T I-59.20 OJ - 1 x,SEI S h FQ IvO $ ( T) ` 71 - - EXISTING LE,ICHING CHAMBER i - 11,000 GAL - MAINTAIN AND PROTECT Up MAI;NTAINC,80 PROTECT t -- - -- - -" k RIM = 64.8 �/ ✓ �, f DMH 30 SETTLING 6"PVC _ : 6'S �"'4 EXISTING GREASE TRAP _'EXISTING HYDRANT `.�----r j' R=50.9 LD 1 DMH-36 1 `. .:,- _ ACH,� n { TO,BE MAIN'(AINEDf / I I=48.80 DMH-29 L. TANK- (,' -IR=65.5 "- �` , ( _ •�-..,, INSTALL 12 45 BEND I=48.7o (OUT) 1 /Y / ® - I=56.5o OUT AND CONNECT TO - ✓ I •_ . VA VE ANHOLE` EXISTING WATER LINE - // � DMH-29 DCB-19 $,.:..., 12--t7-•�------:_----_ y , _ _ SMH-14 - �' J- - - - 'REMOVE & RELOCATE R 56.8 R=60.6 8 S - -8 S- - - r - -� ___. . ', 12 PIPE J _ - - R=64=4, -a _ -� _ -" --- - i- ti / I-50.t0 DMH 28 `' I-58.t0 (OUT) � �� o z XISTING HYDRANT _._------- ."-"•- ., t _ q \j\y I=50.00 OUT _=54-80 SMH-13) _ " 12 W _J _,.. bti,:,c. - 1 [--54.7o(OUT) DMH 37 2-2 PVC _ _- - -; 72 _ ,. •. s ;3sc, _ _ �8 _ u c„I \ .• 2 -- x ' I 1 l 1 i 1 - ___ -- o I 6 -- -; RELOCAT<= ti A ti�� t RELOCATE FORCE MAINS " , r .WG' ... _., .�---- / E _-�•- r' ' __._- _ ..�.-------"`�- _, ask ,_.- A METER I ,--- HYDRANT 1_ _ 1_ 1� s~ � �._-- _ _ .8 __ 1 1 I 56 80 DMH 37 __ w _ � ,: g, ,- ( r r 1� _ .. _ _ i - � - ..... -.s _ .._ � {J IlRMCLPI R UNIT 56:50(OUT) T , , _. ♦ x GA4S c ._.. _ :.... ._;. � _ _ _._------".��- .. ,cA /, _ ,u._- �,. x.. t�. j7 ,, R=66.4 00 - /f � N PROPOSED STOP & SHOP N I ,__--- I 11�� ,, ..: � _._.:_..- I=61.75 DMH-35 1 I r I i t F 2 I I li 1 f f f t t----t- I I I / �- 1 y,; � I� / / ,/// /, �, , � 15; , 12 D r"" -r-r r f f f I 1 f t ,: "-----------"`�-� � x`. SMH-5 � .� i o40 u," / P ( , F I:=61.50 OUT) I=58.00 I I t-h tr"f�1 1 I I I I I 1 I (INFILTRATION BASIN I I /+ �� -F- F�"f I i f f f I I f I r I I I 1, �, - � `/,✓//p'`f/ff/ c, � R=ss.1 cpRtt�K :�= SUPERMARKET f f I f f f I I f I I f o 1 125 CULTEC UNITS I 1 1 <,„-- , _ , -.►� / / f,/// / n i I=58.2D SMH-4> _ ` F, Ff} P::'( 12 D n?.CtO 3 ` ® I I,I,I,I, I,I,f,I I I I IAA; © t I I 72 UNITS WIDE I I 1 I k_� 1 G.� f t f/ t I 63.50 , 6, DMH-37A _._ - -" cn t f _ f t 1 I I I t� I I I I f I f17 UNITS LONG 11 1 1 f I -- 1 ..., ///f k - t I=63.1 o BLDG) / 1'. CMH`-35 N FFE :-_ 65.0 R=sa 3 1 DMH 14 I h L-1 ,f.I,I,I J,.. rl } i�//. I 1 SMH 6 - I sa o our) ♦. HYp we l R ss.o 4 I1 R-626 ( I I I I �Tg�uK 1 1 t I I I ! f -- I 60.00 RD �o S SMH-7 1 R=69.0 ~ i /f 1=6260 (DCB-22 r _ I t I I EA! �FRC -- DC6-8 I I 1 I k / MAINTAIN AND = MAINTAIN AND SMH-4 `,k O `� ( i ! I I=6270 DMH f 7. T 37 50"- BLDG) E1 I=58.70 DCB 28 -- _ R=63.2 I I I I f I 1 r I , ( I I I ; R=6s.2 - PROTECT EXISTiN�;•. I 58.00(SMH;5) PROTECT EXISTING R-68.2 ' I-57.20 (OUT) f I=58.40 DCB-16 1 f I 1 I I I f I t 1 1 1 I I I I I 1 I I 1 ( ) I-59.10 �SMH�3) S cnw -- - - I=59.10 DCB-8 ( I I I - I I I=59.50 (OUT ( I I I RECONNECT / I 57.70 SMH 6 I=65.00 BLDG) _ t I200 (OUT)SEWER CONNECTION 1-57.90 OUTY SEWER CONNECTIONS '° sliALLow ( ) - / I=64.50 BLDG) I=62.30 BLD f• r ✓ / I=61.00 I f I=58.40 (OUT)- I I I rf I I I f " I'` 11 I 1 DMH-15 11 I f I 1 1 GAS LINE �NTER I-57.60�ouT) k ,f/f/ll-r / ', C f///% l I=59.00 OUT) - «f L k ^A N % k f, /i// !ram/// r { =, l,p ec6-22 �p DCB-16 I f 1 1 1 f 1 1 D 1� `° 11 R=626 I f I I, T f l / x G ■ `D� / , ! / ,/yy` _ SMH-3 °r 6 S i 1 sE=.k-'6s.3 1 - --- H( INFILTRATION BASIN - f - I f 1 1 f i=58.30 DCB-17 I LV f 1 r I - / lf1//�>t _ 1 VI R D -1 1 R-623 I I I i I / /✓✓f/%Iff _ _ t �y R=66:1 _ d L. S� '' J` F-6260'(OUT) rF _ . , WG 225 CULTEC_.UNITS'" I I 1 I t I t I 1 I 1 I I - 1 1 I k / / s $I_61.50 1 :2 3 1 AD IJIiN� } -- f I=58.60 (OUT) ( I I I 1 1 I I I I-57.80 DMH-1 F 1 I I f I I 1/f CIS 1 1 �` 1 ca I -15-UNI7S WIDE I f f 1 I f 1 ��v 11 I=5770 ouT I f ( I // N I -17 I I 1 I p I I I t�l I f I t n / /!1/, T .M T9R NIT / Y - 15 UNITS f DCB I I f f i - rgVsRT=6o. ' I I /�,l� /' � I.------" `p---- � , ,'� �'q� I�--6�.90 t`' ,,,, >�'=6 .3,d: _,T,. < � � f,Rrn���Y C�NTQ COGS �»'""_-•_-� j tl RECONNECT BUILDING I I R-623 I I I DI 16 f 4. f SC 1 / L/1/ t I=61.00 0. I R%6 f it � l � � � R=66.5 600 ///� �] _ . 3. f I=58.60 (OUT) f t ► f i f ) 1 I IT /j _. . r i , k t SEWER TO SMH- rr, I I I I 1 I-57.30 =1 I I I f I-58.60(DMH-6) r 1 - - wOUTLET CONTROL O x I I I I I I1 _ )6 LT 1 ) ff�/// t G ~� } SHALLOWSTRUCTURE "� 1 I FfII57.30 DMH-1 ) 11fl ,/ Q \ ?� r �F= 8. ( ) � ,..----;__ `-' RETAIL A i�./ ' _ = MAINTAIN AND =R'-TECT i I C - / /EXISTING J(VATER, � S ANDt=66.60DMH-28 I-57.10,JDMH ou 11 1 I _� c�, I ) B 1 //f, k-�' I I Y I 1 t I k I r I I � � ,.:,- � t , .-- 1� =64- t 1 R-59.2 4 -► _,� - ..� -. � ~=- CABLE CONNECTh:)NS INVE, � r ; (OUT) VV 4""D I t I=50.80 (FES-2 , ( 8"F I 1 "D 1 1i / R_68.1 f `59. '� i 1 I=54.00 12"oU r 1 I=59.30(DMH-5) - 1 r r'i �00 30" LVL HDPE / ( --24"'J �-24"D I=59.30(OUT) = (:ONNECT ECISTII�G ROOF DRAIN I=56.00 WEIR) y, 1 r _ - _ _- T-53.00'`OUT) /�`L " DCB-26 DMH-18 " 0 0"" LVLL l :, 2 1.0 LEACFIING``CH'AMBER WITH �, ,r v v R=6t3 1 Res DMH-17 24 D toa 1 ' DMH-7 - I T 1; RECONNECT - I=57J (OUT) I=60.00 RD I R=624 L 165.6 ® _. / Ei` DI RD (LOWER-AS NECESSARY FES 27 GAS LINE 0 0 PROC7tDE A" OF COVER). 16 D.I.�f .- G I=60.00 RD; I=56.50(SC-2) / r I=57.85 I I-5t.2 (DM 28 �- 1 v " GM c I¢56 50DM19 I=56.50(OUT) 2 D ✓ ` 1 I=56.50(OU� ` "� 12 DI DMH=2., .,..' ' a �-' '•, ` � r I=56.50 (OUT) U I I ,. •.0 k ! _ _ t~� _ 4 I 55 60 DMH 2 r .-.. '.r..� H Y --.D _ N.ti+r TI i _ (OUT) S MH 13 I _ } s.t I 55.60 i. _ \ r , l t E _ _ . tt . 1.70 CB R -. _ --- -.-.,-... - ---- TIRANS ORt,AER P .. 1_�„ Y. JLI � 3 i �._ _ DCB 5 .�� �INS. 54.00 a _ � �- _ OC TE --- ---- II N _ REL _ 1I � � �_ b9.8C 4 s. �, � � .--- - .. - - . I DMH a I s6.6o ) DMH 1,, -- _ _ o ---- I - !. _ _ L t _ \ v DMH 26 _ � O I 59.80 OU R _ _ r7 , -- -STORMCEPTOR-"t1NIT _ -�- 6 DEEP ( L.: g/ , I 56.00 GT 1 I I R 62.5 t _ � - _ NOTES: - _ 60 72 --- :, I-63.00 OUT - \ " R 61.0 I 61.00 - � f--'ORMWATER I=55.90 OU : _ •; : 12 �BLDG T) � SGc2 ., I 59.10 ,{DCB-1 $0 x72 I �DCB -- I, 1. PUMP AND FILL EXISTING SEPTIC TANKS. � `I=57.00 I=55.30 DMH-25 . • LEACHING -�, tom• 3 �`r G�S'"I�0�00 - r --= R=62.5 ;12400 --► I ( I=59.20 -2 S CHINS CHAMBER I=57.10 DCB-2s • F -FEELLEACHING DMH-4 . 1 - - M ORMCEPTOR UNIT l p I=55.10 DMH-39 GT-1 1 = a- I=56.95(DMH-16) I 12 D ` I=58.20 DMH-1 --- R=67,i 6" DIA R=67.0 /� C! (� D k C9, _ - - _ • -TA- I=56.70 OUT F- " I=57.70 OU --FIELD---A I=63.'J BLDG �• car I �V� 2. VERIFY EXISTING BUILDING SEWER INVERTS SC-3 2400 - . R=63.8, 63.6 - - ( ) _-_ -- ) _ _ I 56 60 (6 DI) Gw,�T=58 60 - • -- 2 D B- I=57.LO BOTTOM) I 62so DCB 5 �c� SMH-1 i ! Uy�y - � PR R TO NEW SEWER INS TL N R=61.6 , I=55.20 (OUT) I=56.45 (BLDG) / HA W I �- I HALLOW ---- - 2 I=6270 (CB-6) o DCB-2 ,':`• �``� 6 MH- =56. 0 OU I=61.00 / -_ _ --- l o ¢O _ - = R=67.6 SMH-2 I 54.60 (D 26 I 2 ( T) ' --- DCB-15 DCB 25 ----�� � , o _ I 60.80 DMH 3 I N �; ss.s.± f'. ., I� � 1 R=71sf �__�•�"` 3. SITE UTILITIES (WATER, GAS, CABLE) WITHIN R� 4 VENT. _ N + � I 66.30 1 I=54.35 (OUT) �' LD LD h DCB-18 ,� --- R=61.9 R=62.7 -- �r Y- I=60.30 (OUT) I r64,0O,,,,(OUT)l,- v5.i ) 1 d R=70.6 UU)I S = TO ROOF --_ _ ---- i. " iy F�- i t _ sD ,.$c1_ I I=66.25,�OUI) ! 1 � -'- N R 0 BE CONSTRUCTED UND THIS �t � ,�-' I� ,�*, I-65.25 SMH-1) ROUTE 28 T CO UC ER R-60.6 - ( " f l-_. - - __ _.- „� CONTRACT. I-59.40 OU p I-59.40 OUT � VENT � '6�r I-65.20 OU .-'-" F 22 I=56.90(OUT) J ' / - ____-___ I oo . 18"D �- c +r - C7E INSTALL r ` ES- E m o D" ( tom µ Z II - *�` ' I - - -S I S .'B 4. SEE SPECIFICATION FOR REMOVAL OF I=50.0 DMH-21 s...%� :.-- '" �-j""1 _ "" ,.�� Q � � "'� VENT I� < _ 'i „� �, I , ,.� � 1 3 S DMH 1 --------- 1 CB-7 o DMH-2 IrI g ):INSTALL �- EXISTING SEPTIC TANKS. w N R=65.7 N _ _ R-68.0 r t PflE ;:3ts 5 " I' I 8"S � r' R=64u SHALLOW I l ! W W DMH-3 0 - 2"V}'ATER 1 I=60.OQ` RD) ., DMH-12 N I=62.00 OU r R=67.1 _ t I?,S RlI3,, I II U = 8 :STUB .. - 1 DMH-39 i 1 I DCB-14 I R=62.5 I I=63.70 $_2: 4 I=63.60 DCB 2 ° } �, � � ( � J � - CEAC ! � � I=63.70 B-3BOXR=60.7 I=56.50 bMH-18 R=61.9 I=59.10 (DCB-1 1 co t L.EACHING I-61.00 HNG LEAC> ING =I 6230 DM I=56.80 DCB 3 ! =56.50 DMW-20 r I=59.40 (OUT) 12 D I=59.20 (DCB-1 Q ?eclP I=61.00 ) =w ASIN BAS+" -. 3 ` _ II a- I=61.8o (OUT) MAIN I AN PROTECT I=56.50 DCB-1 N I=57.70 X --► I I-59.10 DMH-11 60,c72 ( 17 I 56.40 OUT) « E 15 D I 12"D II=58.70 OUT) RESERVE ; �' ,��, O ~ ` f J II 1. 11 ` oo I 0 6 Dim L=5S.00 I 60 x72 I f I t�� EXIST G A ( AN \ s I � �, I t (SHALLOW LEACHING AREA ' 1�L, W z CB-6 `� I l I - o w = RESERVE DCB-3 DMH` 1 GAS ERVICE TYP. 4'S 1 aD _ w - I=63.00 OUT - II �r rYkY t I I � DCB-10 I ' '�i G. a �• � � � I-63.90 r R 67:6." t` R-69.1 � � I' =, €'�` I � I LEACHING AREA I �o R=62.7 I 1 Mp I=64.00W.OUT I`=62.90 D -1) } f EX SMH ; `q'F ( R 71.0Ep INSTALL p o I I=59.4o (OUT) EXISTING BASINS TO V J _ 1 _ y \ ) 1 DMH 38A - -- --- - 1 3 BE REMOVED TYP - ( � ) o - - N_ A' ROXs},.A1E LOCATIONS 1 1 I I I-66.50(8XOUT PLUG R=60.6 I ( ❑� -�J -1Ir N d I ;� iI l �= OF AN'TARY ITSI{ K ; 1 I=57.40 BLDG • • I=57.30 (OUT) / r 30"D co �--30"D Ol p/ p B j ! iI I ! T 57.30 6 1 J WG 0 CAL) p ©!I r M INT I EXISTING ( I I<� i B ILDPN CONNECTION it t / 1 - I , r - } " � J � II� ?I; M IN;TAI AND PROTECT t` --► 1-' 8 W CONNECT , ILDING psi „; OU CON�R 8"W _ 8""W 8 W B�1 _ - " z - " " - ., ;I TI HTT NK AT -.� _ ,c_ DMH 21 i 51>� o_ DMH 11 i �� « 1 6 W �-_,. c� ...- SEVER TO.SMH`'-10 �. . '•� • ,: I +_ -,, �.r.,...-� �TGhT TA,JK u.' j12 D g .- R-67.2 5 D (7 ) „ cv _; ! . D C AVERS w f. 1 DMH 20 6 S = , �-- 6, .. '� '', " Ig526O(DMH-20 . f R=64.5 ` j I ,60.60 CB-.3a " WG i / 1 I-61.80 1 �-12 D J - t i I=64.00 BLDG r .� 25' } Yb 1 L.=60. Q�1 HY I CB-13 � I=59.50 €DMH-11 OUT)... � 1 It I=60.00 (�RD) H p DMH-38 I^_56r89'°'(DMH-19 WG R=ss_2 r.S AIL ii R=624 .I I=55.60 (OUT) ( I=61.50 (OUT) fO� Y 1 HYD _w. f ROI-V�7ED z SMH-11 \ APPRL)XI ' ,TE LOTAT10P t?F d } I=}57,90 CB-27) ! ( �`p' SHALLOW _ �u R=66.5 ffl SMH-10 ,P,(SANCTA PET kN SE I=6280 SMH-10 R=69.1 NIIOLE W(TYP) r ® r / 'v1Al DCB-9 I=62.90 BLDG E I-65.0o BLDG) " -F Z NTAIN AND 1 WG = _ l '' 8 X8 X8 20TECT EXISTING 1 TEAM COMMENTS 9 13 01 :��..% '� RETAIL D sTi r / 0 I=57 90(OUT) 8 41Y, FFE= SS I-63.50 �BIDG D� I-64.90 lW>� S NG IvPY SM64.8 r ,r • p R=65.5 s I I=64.00 SHALLOW t °CIS 6"X8" REDU ER � 11 I UTII-ITY / f WG INSTAL I R=64.8 I=63.80 OUT)_ S I=6270 (OUT) 0 �& ) CONNECTIONS' Revision Date Appvd. DMH-20A Z g" TDg I=ss.00 sMH-11A FFE = 67.7 • CB-4 =67.1a R=63.1 t I=56sa(otrT q DMH-10 SMH-11A I R=6 : CP CB-24 � . 1 12"X8"X12" TEE _ C'r R=67.3 R=67.0 _ `� _ - Designed by Drawn by Checked by �' 1 P-F89 i,�-' I 60.00 RD , � � I.-66.50 (oU �" �' -,. S.H41nw � -.,.- / ,- � /.'' DH WH DH/EM J 1 - 8" GV = - - FROM 's 'RD S-BACK LINT I=63.70 CB-12 I=60.)0 SMH-11 .. !!r^ _ ._.�I 5U.00 .-RO _ nor+ �®: _ -_� � .-._�- ( GG G - / r �/ _.�_._._ �J N ._.- +,x`..","".:._" CB-23 � s^ I-65.30 6 3 Y Y 2 - 12"'GV CB-21 I=54.60(DMH-20 -DIL 1 CLE _ I T'=6_SO�DCB_� -Lv59.80 (oU -- _ ---- ,^ I I=65.00 U WH DH _ � o � � CAD checked Approved R=62.4 I=54.50 (OUT) - I=62.0D- OU>) v -- _._.__.._. R=68 8 �� j / • - SHLLOW _ - -- - __ - 7DEEP I f =68.1f I=66.30 (OUT) ' i Scale „_ b , Dote bI=58.70(OUT) SHELTER - __._••- ��, f;/� ` _ - 1 -40 8/02/01 -_,Y �r ,V Y"fiDEEP t C -12 �'ti^U. `"yam _ CHING CHAMBER '/. LEACHING CHAMBER _• --_. - R=67.0`- 6"DIA: _ / %!/ i ProjectTitle I-64.2 (OUT) I=64.00 BLDG ' CCy R=66.5 6' DIA. ® _` ( 1� - .' •- 0 � f 1 � _ ETA 2"W I=62_80 BLDG = .., --. RETAIL C LiJ O I-56.00 BOTTOM) %/ C )pG-� _ -_-- \ I� I Cotu*t Landing cn _ . i 3 I=56.80�BOTTOM) ` _--- _---• t MAINTAIN AND PROTEC 1 I XI TING UTILITY E CONNECTIONS / .% / ,. , ----- _ Redevelopment /',.i ` •-._., _ DEEP-� _ t CUB D APy --s = r I � •1 . . . -{3H - . . . _ __ __ Y •-_• __-'- co4 R 71 OHIN AV DIA. c�a - t AS LLI 1E , -- ._.. I and Expansion LJ_JJ s , _ • , ._._ , . . , . __ �, -- �� I - 54.0 (BOTTOM) -- __ _ -- _ _ ._. - --. _ amstable Massachusetts 1 Issued for _- __-_ . 8 GAS- _ ---°.•..�-•. lr '+--y .� _____:.. • ST RMCEEP NIT:-:-•�____�___6 _ Bid � "GAS ------- N D E D I N THIS CONTRACT w - - -- --- - / - --- 6RJls I, _:.�t3A W c�u - 1} U _ AQUV l�I ROAD) ---- - _Mr -__ I=64. a 1 REPLACE 4" WATER I=64.70 CB=24 •--._____,.-.,_.D GAS- ..----- , GI �T" ; -- -- � �o"GAs- Not for Construction / �` '"y 'WITH 8" WATER s I=64.45 OUT) O 1 f,___..__ _ .___.. _ -_. "- -WG. � Drawing Title / INCLUDED IN THIS CONTRACT - --- -...____:_.� ___.-_____ -_. Y NOLUDED-A THIS CONTRACT STU C 6 w U \__12"X12"X12" TEE f _ _ UG _ O 12" PLUG 12 GV (3) REb10 6" STUB, Q _..__ } p Plan 1 q� INSTAL 8"x6" EDUCER __ __ Utilities 1 lan � I AND 8"ti-GATE VALVE ,5;� 12`p- APPROXIMATE LIMIT OF WORK r i TO BE PERFORMED UN ERA APPROXIMATE LIMIT OF WORK SEPARATE OFF-SIT IMPROVEMENTS CONTRACT TO BE PERFORMED UNDR At, / SEPARATE OFF-SIT Drawing Number IMPROVEMENTS CONY RACY53 g 40 0 40 80 I ` • CIS 7 / - C-7 SCALE IN FEET : 1 "-----•-'---,-_ Sheet of ! 7 16 Project 71 .a: I :''' r t'{� L✓ �'r~'' 05162 umber 05162\...\PermitsV.ocal Approvals\5162ut.dwg --- - --ZENON WASTEWATER TREATMENT FACILITY EQUALIZATION TANKS 1= 60.86' (SETTLING TANK) j ANOXIC TANK AERATION TANKS BUILDING 63.19' (AERATION TANK) 61.59" OUT CONCRETE PAD DOSING PUMP STATION m� 410, O CONCRETE P R= 64.92' 6" PVC CLEANOUT m0�� ' 1= 60.03' (BLDG) 3 I'g 1= 61.59' OUT D� SETTLING TANK 1= 62.19"OUT SMH-14 R= 63.94" S VALVE CHAMBER 1= 54.25" (SMH-13) RECIRCULATION R= 64.04" 1= 54.20" OUT I VALVE Box 1= 53.04' (DOSING) LS-1 1= 53.35" OUT R_68 92� R= 65.07' BOTTOM= 52.64" r 1= 53.18' (SMH-14) 5.00 O 1= 53.30' (BLDG) Ln = I 1= 64.02" OUT co o u- 06 W Ft �z u Zc� � or _ Ww n- m Cn D ❑ ❑ 0co { O Ir h0 I=54.5" SMH-13 i R=63,55 1= 55.43 SMH-12 58.00 1= 55.47' (BLDG) 58.03 57.99 58.03 58.02 57.95 = 55.46' (GT-1) != 55.40" (OUT) 57.97711 I 57.96 57.97 6""S 1=59.47' 60"x72" x 57.96 58.04 x 57.96 s GT-1 LEACHING R=63.63"63.61"63.67' FIELD A LEACHING a 1= 58.42" (BLDG) 6""GW 1=58.58" . LEACHING 1= 58.26" OUT 57.98 x 58.03 57.97 x FIELD 57.99 4"" VENT 57.98 57.95 g TO ROOF VENT 58.02 _ _ 57.95 58.02 58.02 58.02 58.04 s VENT BOTTOM OF STONE=58" BOTTOM OF STONE=58" Q IcQ J IT- _� I RESERVE I RLSERVE LEACHING AREA - I M 1=64.2 ' S' S Q" SAML S S 8� S 1 I 1=64.81' SMH-11 PROPOSED R=66.45 RETAIL D 1= 62.78 SMH-10 SMH-12 1= 62.70" BLDG E) 1= 63.28' (BLDG D) R=64.43" 1= 62.70' (OUT) 8" STUB 1- 58.63' (SMH-11A) SMH-11A 1= 58.60 (STUB) 4= 1=58.59" OUT R= 66.89' 1? 1= 60,46' (SMH-11) GG G 1= 60.28' OUT BICYCLE SHELTER ROUTE 28 (FALMOU TH ROAD) 59.49 f--- 59.51 - - 59.46 1 59.49 59.51 -- 59.58 59.431 59.53 59.60 60"x72" x 59.41 i 159.48 x 59.37 LEACHING 60'x72" FIELD A LEACHING 59.39 x 59.46 59.60 x FIELD 59.39 59.54 I I 59.59 B ' 59.451 59.62 59.60 I 159.70 59.67 59.49 'F- -" - 40 0 DETAIL S( TOP OF PEASTONE (PLAN = 59.58") � I - L. -_ L ----- - ----__ -1 I,----- -J ____, .1 ---- ­�. �� ­- -- � 11 L . . I - I I I -,, ! 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