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Home My WebLink AboutFANCYS - FOOD FANCY'S 699 Main Street, Ost. i "r Town of Barnstable BOARD OF HEALTH John T. Norman Board of Health Donald A.Gaudagnoli,M.D. BAIVIRTA19M F.P.(Thomas)Lee,. MASS. Daniel Luczkow,M.D. Alt. +o � , 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 30SA, 3056, 146, 189 and 189A Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 764 Issue Date: 01/01/2022 DBA: FANCY'S OWNER: OSTERVILLE MARKET PARTNERS, INC. Location of Establishment: 699 MAIN STREET OSTERVILLE„ MA 02655 Type of Business Permit: RETAIL WITH FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - MOBILE-FOOD: MOBILE- ICE CREAM: C�� 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: A ax�,( s _ For Office Use Only: Initials: —7• WE Town of Barnstable Date Paid InspeBARNSTABM ctional Services MMA 'Public Health Division Check# Thomas McKean,Director l d ( 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Pas: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: �L� \C ADDRESS OF FOOD ESTABLISHMENT: CD6L MAILING ADDRESS(IF DIFFERENT FROM Al#OVE): E-MAIL ADDRESS: • E, TELEPHONE NUMBER OF FOOD ESTABI ENT: CIL-)4wo - 1 t kl TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO11.. (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 REOUIREMENTS. 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) ZFOOD 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 "�; OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES NO OWN``ER PRONE # ADDRESS ec� cad L CORPORATE OWNER: Z_ CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **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 ��ML O,4 / 1 a /aoa6 1. Il / .?,-o / 2. 04/ 1 a /Rj�Rb SIGNAT74�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 wha 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 httu://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec. 3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Town of Barnstable BOARD OF HEALTH � John T.Norman Board of Health Donald A.Gaudagnoli,M.D. EARNi�Y'ADW =" Paul J.Canniff,D.M.D. F.P. Thomas Lee Alternate laA 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: 764 Issue Date: 01/01/2021 DBA: FANCY'S OWNER: OSTERVILLE MARKET PARTNERS, INC. Location of Establishment: 699 MAIN STREET OSTERVILLE„ MA 02655 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: ( FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I .5 �f Town of Barnstable NE Tp� For Office Use Only: Initials: � � Date Paid �Am}�Pd$ BARNWABLE, : Inspectional Services n/ Check# p,Eo ,.a 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 NEW OWNERSHIP p RENEWAL ` f \per NAME OF FOOD ESTABLISHMENT: uc k "}�" � "� \ ADDRESS OF FOOD ESTABLISHMENT: �p�q ray r1 1 ~R�`�A'�5� �.VV�P`C32 ` S MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: - (9 TOTAL NUMBER OF BATHROOMS: ` WELL WATER:YES NO_AZ ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: ✓ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE:—1 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*** 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 aLv.;ZI—�K �` r SOLE OWNER: YES NO OWNER PHONE# ADDRESS oZ_ 2 - is l CORPORATE OWNER: 1 CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: 1 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 dot e-Dtb 6��-- I SHNATURE OF APPLICA4T DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3Is'each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Application FonnsT00DAPP REV3-2019.doc # Town of Barnstable BOARD OF HEALTH I John T.Norman Board of Health Donald A.Guadagnoli,M.D. s� rAa F.P.(Thomas)Lee t 9. 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,Alternate 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: 764 Issue Date: 1/1/2021 DBA: FANCY'S OWNER: OSTERVILLE MARKET PARTNERS, INC. Location of Establishment: 699 MAIN STREET OSTERVILLE, MA 02655 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY rr, f For Office Use Only: Initials: . Town of Barnstable Date Paid I Amt I'd$�� BARMN g Inspectional ServicesnAss �C n i679 Check# 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 H DATE I o'2 NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: CL ADDRESS OF TOBACCO ESTABLISHMENT: . MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: cu ' TELEPHONE NUMBER OF TOBACCO ESTAB MENT: &ED 69 OWNER'S NAME: - _ OWNER'S PH#YO ,) s OWNER'S ADDRESS: _._ CORPORATE NAME: CORPORATE ADD SS• _ c1 CORPORATE FID# ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE CODEMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: A https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: http.s://malegislature.gov/l,aws/GeneralLaws/Par.tIV/Titlel/Cha pterVQ/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 I F SIGNATURE: PRINTED NAME: \- DATE:. el I I Zp2� a Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx s t. EgrABLISHMI;NT'S NAM 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: _ Sates to Niirittrs—-.3714 Sale and>4istribution 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 dam of birth that the purchaser is 21 years old or older. Verification is required far any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable B*d of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: ,1161 Rel1 4hn !`Co Si afore Printed Name Date ZdWll Llw C, Signature Printed Name Date ted Name Date 447 Sj'uattue fed Name Date S Prin Name f Date S'finature Printed Name Date — 85 02C� Signature Printed Name Date Q:Wphcation Fonffi1TOBACC4 APR NenFavw 12-1&19.dm rs f SptL=rF Commonwealth of Massachusetts �w • „r' � tj Letter ID:L01350S972S � , vcri=i—IJ Department of Revenue Notice Data September 1,2020 �'f'? .. 2., it 5 Geoffrey E.Snyder,Commissioner Account ID:CGL-10276794-007 1TOF� mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES Illlllllllllln(ll�lnl�lllll.,ill,Illltltllltlll�lilllllll o= OSTERVILLE MARKET PARTNERS INC o= FANCYS MARKET 699 MAIN ST OSTERVILLE MA 02655-1903 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3). Cut along the dotted line ------ — ----and-disp.lay_at y_ou�businea�ocatlon.. At any tune you can log into your MassTaxConnect account at mass.govlmasstaxconnect 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, 9:30 a.m. to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ ,�5 `s,�T� MASSACHUS.ETTS DEPARTMENT OF REVENUE"" Form CT-3 Retailer Retailer License for Sale of Cigarettes z `, Fir.. -4*' This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. OSTERVILLE MARKET PARTNERS INC Account ID: CGL-10276794-007 FANCYS MARKET License Number: 93689856 699 MAIN ST OSTERVILLE MA 02655-1903 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2020 Expiration Date: September 30, 2022 n�ft4;cF Commonwealth of Massachusetts Letter ID:L0980039232 �0 • - September I,2020 ElF Department of Revenue Notice Date:Se P p it "-€ D GeoffreyE.Snyder, Account ID:CRL-I0276794-010 Y Commissioner ' rc mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO t +�Il�i+ml++�Ilr�+Illlllii+ir�r!"�+�m��I+Il+lull+Ills+fl OSTERVILLE MARKET PARTNERS INC o= FANCYS MARKET N� 699 MAIN ST OSTERVILLE MA 02655-1903 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut — along-the-dotted .ine-and-disp,lay_at.your business Location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a espy oTt tli s 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 ---------=--------------7---------------------------------------------------------------------------------------------------------7-------------- '`cHos�� MASSACHUSETTS DEPARTMENT OF REVENUE " -___ Form CT 3T Retailer License for Sate of Cigars and Smoking Tobacco F4�iro1i ` This license must be posted and visible at all times.The sate of tobacco products to anyone under 18 years of age is prohibited. OSTERVILLE MARKET PARTNERS INC Account ID: CRL-10276794-0 10 FANCYS MARKET License Number: 858.908672 699 MAIM ST OSTERVILLE MA 02655-1903 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1, 2020 Expiration Date:September 30, 2022 -Iassachuseft'D Partment of Revenue - customer Service 8eneau PO Box MO + Boston,MA 02204EASIER MI P tt v. d N. n- - to sell tangible personal PropeM at retail or for remle,,pursuant to the The vendor herein narraed is tiered _ - -on is effective only for the, nt at the location General Laws,Chapters 62C,64H and"- Tt"ss regrstralt exit of Revenue so that a specified herein- Any change of name or address must bs r Ofted to the Departm Correct ST-1 can be issued. mnca NUMBUz MVI€,LE X&F.KCT PARMURS 472r807-909 FANcy5 MARKET 699 MAm SST _ MSMnn,E BABNSTABLE MA 02655 7lJES a TTus reestrRtimmut be&*Ryed ft cjstamms to see and is not assig'"Qrbmdt' O OF RBVEN[TS January 31, 2018 Ms. MaryBeth McKenzie JU Public Health Division Town of Barnstable 200 Main Street Hyannis, MA 02601 Dear Ms. McKenzie, I am writing on behalf of Fancy's Market, 699 Main Street Osterville, MA 02655,to request approval to package raw meat and poultry, using a reduced oxygen packaging method that, according to section 3-502.12(B)(2) of the 1999 Food Code, limits the food packaged to a food that does not support the growth of Clostridium botuAnum because it complies with sections (13)(2)(d) (raw meat and poultry have a high level of competing organisms). This reduced oxygen packaging method does not support the growth of C. botulinum. Therefore,the code does not require Fa cy's to apply for a variance, but we must have a HACCP plan in place and need approval f om your office prior to packaging these products using a reduced oxygen package. Therefore,we have enclosed a copy of our HACCP plan for your review. In addition, as added safety measure to ensure that non-pathogenic bacterial growth is minimized,the shelf life on the products we intend to.package will not exceed the 14 days allowed under FDA recommendations. The primary reason we wish to vacuum package these products, is to provide a more attractive commodity to our customers. We also have more than one person certified as a person in charge and have trained key personnel in all aspects of the operation. You will be provided with copies of all Food Manager Certificates for your file. FANCY'S MARKET 699 MAIN STREET OSTERVILLE, MA 02655 508-428-6954 ROP HACCP PLAN Raw Meat Poultr / y Inception Date: February 24, 2016 Reviewer: Date HACCP plan will be reviewed annually. Records will be kept on file for a minimum of one year. \tC"' E R T HF2 AT 10 N REED NICHOLS for successfully completing the standards set forth for the ServSafeo Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSO-Conference for Food Protection(CFP). 12881165 5071 CERTIFICATE NUMBER EXAM FORM NUMBER 10/14/2015 10/14/2020 DATE OF EXAMINATION DATE OF EXPIRATION Local laws apply.Check with your local regulatory 68ency for recertification requirements. Sherman Brown SVP,National Restaurant Association Solutions '2A —® % 0 #tl866 ---------------- a In aaordonce wnlh Maritime labour Comentron 2006,Reaolul an ADM N 0d8.201 i Fegdatian 3.2,SWrrdard A3,21. '02015 Nalioml liesburint Afeod6on Edumtianal Foundation INRAEF)•All right$reserved.Sensors®and the sensate logo are trodernarkg of the NRAEF. Notional Rvd&irenj Aua!p idion®and the arc deagn are imder,tarks or the Notional Rmtaumnl Aseoetation, lhle dacunront icnnot be rejxoduced ar olloted v.140) Conrad we w th questions at 175 W lackeon Bl+d.$te 1500,GhKago,Il.dOdOd or SanSare®restaumM org. 1d1,029G1. The HACCP Team for FancV°s Market The HACCP team is comprised of individual who, because of their experience, background and vocation,can provide specific knowledge and expertise to effectively ensure the safety of potentially hazardous foods. They are committed to identifying and correcting problems with receiving,storing, handling and serving of food products before consumption. ilntroduction Incidents of foodborne illness,especially those widely publicized in the media, highlight the problems that need to be overcome to achieve safe preparation, handling,storage and distribution of food. They also act as a constant reminder that foodborne illness occurs even where formal national or local government controls are in force. Routine inspections of food processing operations may help to ensure that food is prepared in a clean environment, but often cannot control other factors that contribute to foodborne illnesses. Carrying out daily inspections is neither practical nor effective. One of the most effective preventive measures to deal with foodborne illness is to educate food-handling personnel in safe practices. Purpose As members of Fancy's Market HACCP Team,we have responsibilities that extend beyond cost control and profit. The safety of the public is our first concern. This safety is determined by the quality of the food,the people handling the food, and the facility. It is up to us to make sure that everything possible is done to provide good, safe food. The goal of the HACCP Plan is to effectively ensure the safety of food in the meat department of Fancy's Market. By establishing the procedures and policies necessary for implementing a comprehensive sanitation program, and subsequent HACCP plari, our complete operation will function in a more consistent way. This preventive approach enables us to predict future problems in the food operation,thus allowing corrections to be made before any illness or injury can occur. HACCP Plan Overview for Reduced Oxygen Packaged Meats and Poultry The intent of the HACCP Program is to eliminate or control the contamination, survival or multiplication of pathogenic microorganisms in foods packed in a reduced oxygen atmosphere. We shall maintain a copy of this program on site for review by the Town of Barnstable Board of Health. Foods to be Reduced Oxygen Packaged Raw whole cuts of USDA approval Meat and Poultry marinated to enhance flavor only and do not affect competing organisms. Equipment and Packaging Supplies A list of personnel, authorized to use the vacuum packaging machine, may be found on site. Equipment and packaging supplies will be used according to the manufacturer's directio ns. 1. We will be using a VAC MASTER VP 215 2. Copies of the operations manual for each piece of equipment can be found in the work area. 3. We follow all maintenance and parts replacement schedules recommended by the manufacturer. 4. Evaluation of the package and seal are conducted on a routine basis. We use the following criteria to help in the evaluation: Each induvial package or a certain percentage from each lot is examined for integrity of Package and seal. We make a note if any indicators of a faulty seal such as wrinkles, and incomplete seal or"puffy" packages exist. If these indicators are found very frequently, retaining or maintenance or repair may be necessary. 5. The Cryo Vac machine is located in the wrapping room. The machine is cleaned and sanitized before and after use. SSOP Corrective Action Should the integrity of the package (Holes, rips, tears) while in production be in question, the Person in Charge(PIC) will destroy the product. f Should the contents of the package (slime, mold discoloration, bloating) be in question the PIC wilil destroy the product. Corrective Actions and Documentation Procedures Labeling • Improperly labeled product segregated and re-labeled. • Products not sold within the"use-by"date discarded-assured removal and destruction of expired product. • Corrective actions recorded on Vacuum Packaging Production Log. • Cause of deviation determined and corrected. Storage • Products exceeding 41 F, held pending evaluation of time/temperature egposure. • Products noted above 41 F for greater than 4 hours will be discarded. • Corrective actions recorded on the Daily Operational Checklist. • Cause of deviation determined and corrected. Verification Process Labeling • Monitoring and corrective action records reviewed on a weekly basis,or as needed,by PIC. • Signed and dated HACCP plan reviewed and modifies at least annually or as needed by PIC. Storage • Retail case temperatures are monitored manually twice a day by meat department personnel. • Monitoring and corrective action records reviewed on a weekly basis,or as needed by PIC. • Signed and dated HACCP plan reviewed and modified at least annually or as needed by PIC. Records Labeling • Vacuum Packaging Production(with corrective actions). Storage • Vacuum Packaging Production Log(with corrective actions). • Daily Operational Checklist(with corrective actions). I I Employee Training Topics • Employee Health and Hygiene • Cleaning and Sanitizing Procedures • Cross-contamination Prevention Procedures • Separate Bench for each Species • Monitoring Procedures Meeting Critical Limits • Corrective Actions • Record Keeping Requirements i Reduced Oxygen Packaging HACCP Plan Meat Department Raw Meat/Poultry (High Level of Competing Organisms) Flow Diagram Receiving Storage Preparation (could include seasoning and marinating) Packaging/Labeling (CCP) Storage Reduced Oxygen Packaged Products (CCP) Reduced Oxygen Packaging (ROP) Steps The room temperature when product is packed will be 41 or colder. Raw products will be cut on separate benches, designed for a specific species (i.e. pork, beef and chicken) in the meat cutting room. The meat cutting room has one bench to do one process at a time. The ROP machine will be located on a separate table in the meat wrapping room. The process will be done with no other activities going on. Vacuum bags are stored in covered containers in the meat room,to protect from splatters. Back stock will be stored in the supply area. Product is then transferred to vacuum pouches, which are then placed in plastic bins. Once all product has been cut,the tray is moved close to the vacuum packaging machine for immediate vacuum packaging (or moved to the cooler for later packaging). Bags are vacuum sealed, labeled a with scale tags and returned to the cooler or into the retail case for sale. f The entire packaging/labeling step takes less than one hour per species, or about 40 seconds per package. i MACHINE WASHING All equipment and utensils (cutting boards, scales, prep tables and knives) will inspected at the beginning of processing and packaging for cleanliness. If portioning and packaging exceeds four hours, equipment and utensils will be thoroughly cleaned,, rinsed and sanitized every four hours. At the end of the day, all equipment and utensils will be cleaned, rinsed and sanitized and the area will be thoroughly cleaned. The chamber and spacers will be cleaned and sanitized daily. MAINTENANCE Daily: 1. Clean the vacuum chamber and spacers 2. Make sure that no cleaning agents containing solvents are used 3. Make sure that no high-pressure leaner is used 4. Check the oil view glass pump for sufficient quantity The 1999 FDA Food Code(Section 3-502.12) will be utilized,for guidance regarding storage times for vacuum packaging of raw meat and poultry. VACMASTER`�' ,z e hem number VMS Mote VP216wk3220V UPC Number 0,UM9221S'8 tsaohine,Type table top ohaar mb machine ConwuetionI StaInlessstad cabr Chamber size 1t2S'z/S23'x S' (WkLxH) Seat bar length 4025" r' '}:. Distance between bars a Vacuum pump 114 No rotary on (gcle WM am). 20-40 Ekebibat Specs tt0 6014A 462',watts M&dvkre dbr*nskww 20'xt4"x1S" (WxLxDa madvine 04 weigm A"ne dimensions 248'x 19"x 19' 24 Ibo>wd). Maohirre weight (boveo Features Domed Rd Double seal wire Shipping I Trek Only MSRP $999.00 Record Keeping Procedures All record pertaining to the HACCP Plan will be kept in the Store Team Leader's file cabinet and made accessible to all regulators during normal business hours. All records, required by the HACCP Plan will be kept together, filed chronologically and maintained for 1 year. The HACCP Plan will also be available for review during inspections. Verification Procedures All records generated will be reviewed and initialed weekly by Store Leadership. The HACCP team will meet quarterly to evaluate the effectiveness of the HACCP Plan to ensure that all critical control points are addressed. At this time, an in- depth sanitation check will be performed, and records will be reviewed to ensure compliance to plan directives. The HACCP Plan shall be reviewed on an annual basis. Should changes be required during the year, such revision dates shall be noted within the footers on relevant pages and also noted on the cover page, along with revised date and reviewer's signature. 1/27/2018 23llSanitationFigl.jpg(450X341) wlr�iazsh, Y--,o- ,ur H. nd gLdwese Vitas Munazu r AM r W- etffalnids Soalp 0 -- 1 mwicze lots man=+us, vc9ia t ma :par IN sue; LIAM - y Iffinse Dryrunt off W, 0-ter''wk-h,ftpQrTOwtj i i https://www.foodsafetymagazine.com/fsm/assets/Image/2311 Sanitation Fig l.jpg pp ISEl TOWN OF BARNSTABLE _ HEALTH iNSPECTOR,s Establishment Name: Date: Page: / .of e fog OFFICE HOURS PUBLIC HEALTH DIVISION • - • 8:00=9a0A.M. • BARNSTABLE. ` 200 MAIN STREET s:so-a:so P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 'g ,63q: .0� HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY AlEO1A°`� FOOD ESTABLISHMENT INSPECTION REPORT 508-862 asaa Name �S Date Z� L e of T Ins ection Routine Address Risk Re-inspection J/ Level Retail Previous Inspection + Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness DID- 131 Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Alm - Other Inspector ('�� Out: Alm Each violation checked requires an explanation on the narrative page(s)and a citation of specificprovision(s)violated. S 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 TO 590.009(F) ❑ /,Af Action as determined by the Board of Health. Allergen Awareness 590.009(G) ® f FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 92 vvV// 7tp 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 d yam" ❑ 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 V .© Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No 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 E er ency Suspension C N Official Order for Correction: Based on an inspection today,the items Embargo Emergency Closure checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ 9 Y ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (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 re 9 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 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 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations obsery , 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) receipt within 10 days of recei t of this order. violation,4 o non-cri cal violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's ignature Pr" t: 31.Dumpst 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 ignat 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) 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-Chazge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.003(C) Responsibility of the Person-in-Charge[0 7-102.11 Common Name-Working Containers* Other* f 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* Time as a Public Health Control Applicants 3-302.11(A) Food Protection* 20 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* Food Contact with Equipment and Utensils* 7.202.12 Conditions of Use* 590.004(11) Variance Requirements j 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 Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 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 1 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(1)(2) Eggs-155°F 15 sec dness* 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved S stem* 4-601.1](A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* PP Y Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg cnw mnooi 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 temporary and - ide in cater- * Ratites-165°F 15 sec* in mobile food,tem or and residential Sources g� P � 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 practices 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. 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 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140*F* (Blue Items non-critical 23-30) 3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the 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 ( ) 590.000 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 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 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 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. oFTHE Toq TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of 3 1% OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. 200 MAIN STREET 3 3o-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS-63. `0�' HYANNIS, MA 02601 MO862-4r. No Reference R.-Red Item. _ PLEASE PRINT CLEARLY � - 508-862-4644 rEU MPG FOOD ESTABLISHMENT INSP CTION REPORT C e S- Name 1�. Date,y Z 2 Tyne of T Ins ection Oamfigwa) outin6 / ` O( _ Address C / � �� J'� Risk < d Servic ion �f� i C Level Retail Previous Inspection I W' (6l�-� Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other n J Inspector Out: 61.1 Grit/ 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) ❑ (� n e FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ac ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities IL EMPLOYEE HEALTH PROTECTION FROM CHEMICALS S ❑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 `te,_ ❑ 5.Receiving/Condition ❑ 17.Reheating V F fd� ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling LP ❑ 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) r f ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP AD ,(� ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY '�M� L� - ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical ViolationsC'e 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. I ❑ 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 re 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 4 non-critical violations 9 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6nnn-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 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) s o within 10 days f receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Sin re Pri t: 31.Dumpster screened from public view I l Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's S' 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 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties Cooked and RTE Foods. 3-302.14 Protection from-Unapproved Additives* Contamination from Raw Ingredients 15 590.004(F) Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each � 7-101.11 Identifying Information-Original Containers* * Require Reporting by Food Employees and Contamination from the Environment 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* 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 Requirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* 590.003(G) Reporting by Person in Charge* 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 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 F9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* y P 7-206.13 Tracking Powders,Pest Control and * 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* egme tiuzoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155'F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency rf 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* 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 g. P �' 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. * 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms ( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 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 3-501.14 A 3-202.18 Shellstock Identification Handwashing Facilities ( ) Cooling Cooked PHFs from 140°F[0 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 5-20411 Location and Placement* 3-501.14(B) Coaling 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. `op THE r TOWN OF BARNSTABLE . HEALTH INSPECTORS Establishment Name: Date: Page: of v PUBLIC IEALTH 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 MASS.. `0� HYANNIS, MA 02601 - - MON.-FRI. No Reference R-Red Item, PLEASE PRINT CLEARLY 508-862-0644 ArFD MA�p FOOD ESTABLISHMENT INSP CTION REPORT - i Name �S, Date Tyne of jyDe of Inspection ORAERn RdGFne" C n✓t a (�. Address �n g Risk e-inspection o S Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP _ In: Other Inspector / Out: 664 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) ❑ `�fiCl�- � , Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ j Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands /1 �,j f/� ❑ 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 I %ems/ yL�e C/. iL✓ ❑ 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 b Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items Embargo Emergency Closure checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ g Y ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B re9-One critical violation and less than 4 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 to 6von-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 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special.Requirements (590.009) Y p within 10 days of receipt of this order. violation,4 to 8 non-cr�l violations=C. 3 Dum RATE OF RE-INSPECTION: . Inspector' igna a Pri 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 Ignature Print: Self Service Wait Service Provided Grease Trap Size -Variance Letter Posted Y. N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003 A Assignment of Responsibility* 8 Cross-contamination 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 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) * Require Reporting by Food Employees and Contamination from the Environment 3-501.16 A 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 Roasts Held At or Above 130'F* ( ) Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* Time as a Public Health Control 20 7-202.11 Restriction-Presence and Use* 3-302.15 Washing Fruits and Vegetables 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* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 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 ' 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and Food 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* 3-801.1 l(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 3-801.11(C) Unopened Food Package Not Re-Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* ( 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 t 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* Equipment* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff-d-ianooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- 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 2-301.11 Clean Condition-Hands and Arms 3401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.11 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodborne [3-203.12 01.11 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 02.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F5-203.11 Numbers and Ca acities* Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products P* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 02.11 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 1Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 1 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 1 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. oaTKEToy, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: .J G v, Page:�_of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. RARNSTARLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified y mass. o MON.-FRI. t639 �0 - '•�- }�^ HYANNIS,MA02601 508-8624644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT Name f Dategal Tvoe of je yooe of Inspection tin Address `� J� Risk Food Servi -inspecti 2C I V J s Level Re ai evious Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Qb Caterer General Complaint d Person in Charge(PIC) ®n ��_ Time Bed&Breakfast HACCP In: I ; (Thif Other Inspector2�1�11 SO Out: /d( 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) ❑ u L �/ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ I/11,! / tfI1 c /f Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ P FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands SS � ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities �v►� � pp ,.�_/ EMPLOYEE HEALTH PROTECTION FROM CHEMICALS AL ' . / A ,9 ZeX4' ❑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 'k o O�p"nnw r�v /��e �P/�. ' ❑ 5.Receiving/Condition ❑ 17.Reheatingmm6a� f rl ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling hag W 1Kf ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control Awk s ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) sj%,t4t` r j y ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP /Qr� g%�� ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY G [�- �[ ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer AdvisoriesLb4�Tqa L &/4 Violations Related to Good Retail Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Ste% w7 (C)violations marked must be corrected immediately. (blue&red items) Co ective Action ReqUV- Criticalejgjw� ❑ No e i�P�Pt� Jib Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ployee Restriction/Exclusion ❑ Re-inspection Schedule mergency u en o 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, Jp- 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 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 i 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 anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 to Snon-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspect s i at 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 /a�turree j //JJ Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Lam!/ 4 d ND 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 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each * 590.004(F) 7-101.l 1 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 7-102.1 l Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* 7-201.1 l Separation-Storage* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 7-202.11 Restriction-Presence and Use* 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* 7-203.1 t Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.1 I Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 590.003(E) I 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 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 I 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 Hermetical) Sealed Container* * Raw Seed Sprouts Not Served* Y 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 * CONSUMER ADVISORY r 3-202.14 Eggs and Milk Products,Pasteurized 4501.1 l4 Chemical Sanitization-Temp.,pH. 1 g Proper Cooking Temperatures for PHFs 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 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* EWeai° 11112001 4602.11 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.I 1(A)(2) Ratites,Injected Meats-155°F 15 sec* aces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009 A Chemical ( )-(D)in cater- Sources* I Ratites-165°F 15 sec* in mobile food,temporary and residential 10 Proper,Adequate Handwashing g, P Y Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 77 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 2-401.11 Eating,Drinking or Using Tobacco* q 5 Receiving/Condition & S 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 3-202.15 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* 3-403.1 I(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* 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A)' Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible t 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 * 5-204.11 Loationnerasion and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and RetentionAccessibility, 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 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. pp IHE r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Z Z Page: of 2, v` W� OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. RARNSr?XLE. • 200 MAIN STREET 3:3o-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3q �•� HYANNIS,MA 02601 M-8 -FRI.s2 4saa. No Reference R-Red Item PLEASE PRINT CLEARLY 508 S FOOD ESTABLISHMENT INSPECTION REPORT ti, INS d 7L'rhkd Name s Date Z Z Tyne o TXp"l Inspection U S O s b ` Address Risk ood Servi Re-Inspection �7i� D Level al Previous Inspection ' _ � Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Tim �/ Bed&Breakfast HACCP In: � ."l� Other Inspector � S Out: �P� Each violation checked req res an explanation on the narrative page(s)and a citation of specific provision(s)violated. ' Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ 1•� / Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ _r (�+t6Qel D eL 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 VV�0)L� iIl j2va )-A ��e ❑ 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 GY.�i�� V W 1 6A X4'rV1 aAeAr ❑ 5.Receiving/Condition ❑ 17.Reheating �j,D / ^� 1��3 v0IIL _ S• �& ❑ 6. ags/Records/Accuracy of Ingredient Statements ❑ 18 Cooling 7 TConformance with Approved Procedures/HACCP Plans Hot and Cold Holding l �� 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 (�iC ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations f4 4Nk- Critical(C)violations marked must be corrected immediately. (blue&red items) 9 1� I Corrective Action Required: ❑ No Yes Non-critical(N)violations must be corrected immediately or Overall Rating ��"`` within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion [] Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health: Failure to correct violations 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 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.PSical Facility (FC 6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must FC-7 590 ( )( ) violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Roi"sonous or Toxic Materials .008 be in writing and submitted to the Board of Health at the above address ' ' ) within 10 days of receipt violation,4 to 8non-critical violations=C. 29.Spegial Requirements (590.009 t of this order.y p 30.Ojher DATE OF RE-INSPECTION: Inspector's " nature Print 31.DNmp ter screened from public view Permit Posted? ~" Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sig ture� \ Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N � � Afo �lPA 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.) °:~ti, .,i .i FOOD PROTECTION MANAGEMENT ' PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) signment of Responsibility* 6 Cruss-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) JD�eimc_nslration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-SU1.15 Cooling Methods for PHFs 1g PHF Hot and Cold Holding 2-103.11 Person-in-Chazge Dudes Cooked and RTE Foods.* 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* g * 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* P g 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 An3-302.15 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) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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. 1 g Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F IS sec dness* 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved S stem* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* PP Y Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* e//°"°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 * 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and 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* in mobile food,temporary and residential Sources - g. Im aTY 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and AutWildhority Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* RegulatoryAuthori[y. 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition r 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercial) Processed RTE Food-140°F* Blue Items non-critical 23-30) 3-202.15 Package Integrity Y Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* ' 12 Prevention of Contamination from Hands 3403.11(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* 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A 3-202.18 Shellstock Identification ( ) 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* • Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Mana 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* f 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 1 Hand Drying Provision 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 1 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. of* fo TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: 'I �"`vlil\S, Date: -( Z v l Page: 2. of 2, OFFICE HOURS PUBLIC HEALTH DIVISION a:oo-s:soA.nn. BARfi)fdkBLE. = 200 MAIN STREET s:so-a:so P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ;'e q: HYANNIS,MA 02601 - 644 08-8 508-862-464 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT j Name S Date Z Tyne of Inspection O_o_Eajjg0(.s_) Address Risk Fo Re-inspection Level Retail Previous Inspection -A -" IJ Telephone Residential Kitchen Date: �- f S ( D Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector ZQ Out: J Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ �l (� - 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 V Zj� � � f'm gm-a" l CAA_ ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals f , FOOD FROM APPROVED SOURCE TIME(TEMPERATURE CONTROLS(Potentially Hazardous Foods) � p ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures / `7 �'✓�/T� ❑ 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 HSPIjLj /I /f/t'V" 7 IM _ 30 Q.` ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY l p r ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories (D as �bme Violations Related to Good Retail Practices(Blue Items] Total Number of Critical Violations . G�" astt� �� S 3 64, 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 g ( )( ) 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 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 i 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 anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 to Snon-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's ignat�re Print: 31.Dumpster screened from public view Sob 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 ( s A q"� Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N / l1�1/t C-al ViuU Dumpster Screen Y N Violations related to Foodborne Illness f Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) t l FOOD PROTECTION MANAGEMENT j 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 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 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties i Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 3-302.14 Protection from Unapproved Contamination from Raw Ingredients ,i Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F (F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* * 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F 7-102.11 Common Name-Working Containers 3-501.16 A Roasts Held At or Above 130°F* Require Reporting by Food Employees and � Contamination from the Environment ( ) Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* tion* 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* 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions I 3-304.11 Food Contact with Equipment and Utensils* * 590.004(11) Variance Requirements 3 590.003(D) Exclusions and Restrictions* Contamination from the Consumer 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 I 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 i 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 3-801.11(C) Unopened Food Package Not Re-Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 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* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* EB°Nvc mrzoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 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* in mobile food,temporary and residential Sources g� P �' 10 Proper,Adequate Handwashing A 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 Cleanon on-Hands an Arms* Condition Hdd A * Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-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 Requiremenpractices ts 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* 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 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 3-202.18 Shellstock Identification ( ) 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: Products 5-203.11 Numbers an P d 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 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. AucoFTKE TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: ~. Page: of P` ~o OFFICE HOURS If It PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSfABLE. - 200 MAIN STREET 3:3o-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified .a y: �•� HYANNIS, MA 02601 MON.-FRI464 No Reference R-Red Item PLEASE PRINT CLEARLY prFD MPS 508-862-4644 FOOD ESTABLISHMENT INSP C ION REPORT Name Da1eq I Type of s ecti n ) p Rout' e / Address Risk ood Servi e-Re_ n qqLevel Re Previous peg f � Telephone Residential Kitchen Date: UU Mobile Pre-ope i nek Owner HACCP Y/N Temporary Suspect III ess t Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP �. Other Ah Inspector pF. Each violation checked requires an explanation on the�narrativ�page(s)and a citation of speci4 f h I/)":�r-W)"I fic 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) ❑ v FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands In, ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities V EMPLOYEE HEALTH PROTECTION FROM CHEMICALS i ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) u ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures / f ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding ,PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) A ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY \yn, q 'S1 1q ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Lu 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: AV 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 todaythit ❑ 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 6=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 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 6rion-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. . f critical water,sewage bads-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-c�Ftical vi lations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 vi tion,4 to 8 non-Critical violations- 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: I s ctor's Signal e 0' nt: 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 C'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.) I FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41 EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) * 7-102.11 Common Name-Working 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 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-201.11 Separation-Storage**Restriction-Presence and Use*7-202.11 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP ' S90.003(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* * 3-801.11(D) Raw or Partially Cooked Animal Food and 4-501.111 Manual Wazewashing-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 P 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* I 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 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°n°e vinoot 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) 1 Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165*F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3403.11(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* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13 Handwashing Facilities 3-202.18 Shellstock Identification* 3-501.14(A) Cooling Cooked PHFs from 140°F[0 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* * 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours 9 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* 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. yoF*KE Tok� , TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: , Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. a BARNSTABLE. = 200 MAIN STREET 3:30-4:3o P.M. Item Code C-Critical Item DESCRIPTION OF Viol-ATION/PLAN OF CORRECTION Date Verified MASS =r. MON.-FRI. �p �639• �0 HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPEICTON REPORT ' A , T t n Name j Date �!Xpe o InspectionAir y ; I g Routine ,Address Risk ood Servi Re-,insp ion Level Previous Inspection Telephone Residential Kitchen Date: ^� Mobile Pre-operation J Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other 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) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ ry _ .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 a ❑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) [14.Food and Water from Approved Source ❑ 16.Cooking Temperatures VS ❑ 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 /1 ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP n ❑ 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. B=One critical violation and less than 4non-critical violations re g 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 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 i non-critical. If f 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 ti 8 non-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8non-critic violations=C. 29.Special Requirements (590.009) y p i 30.Other DATE OF RE-INSPECTION: Inspecto Ig.n r qA /` Print: A 31.Dumpster screened from public view ; �72 7 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N %-.."0 #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's S gnature 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* $ Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 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-WorkingContainers* 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* 3-304.11 Food Contact with Equipment and Utensils Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(1]) 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)Retuned Food and Red or 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP of Food* 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 Waning 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 3-801.11(C) Unopened Food Package Not Re-Served* 3-201.13 Fluid Milk and Milk Products 4-501.112 Mechanical Warewashing-Hat Water Monitoring 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* PP Y Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff-nve 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source - - 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and AutMidhority Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* RegulatoryAuthor/ty 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* * Otherpractices0.009 violations iol debited]ating under to good od retail i� * 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3403.11(A)&(D) PHFs 165*17 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercial] Processed RTE Food-140°F* (Blue Items non-critical 23-30) 3-202.15 Package Integrity Y Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1$ Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A 3-202.18 Shellstock Identification ( ) 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 P Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* 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. r a TT �LLgg� IF 'I 'W h 4 f •w r _ _ _ �• �- _ = =�`F��=tit.�,�-.� � _ � ...,�,.•-'�►.""+.'"�""�-...�w` '� '+RW' � � ' "'•ti+� �,••�' .. � .. �. � ' -•+.��r-.•...tee'-- - • • ryy `_=,mow • • . , ..... t. J '-•� ter.• • .�, . , i a 4 } �n I r WNW i • 1 �� A��y i TW 1 , 1 � • �M i } �ti �;., 9F:,! ��z� ia � �q,_ �_ � �� i, � P �� f a �i f f �:'i� F1HE roW TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: q ;z _ HEALTH* OFFICE HOURS LIC eAn�srAe�e.o PUB200 MAW STREET SION 3:30-.4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified l( 3:30-4:30 P.M. tl MASS. 0a _ MON.-FRI. �A ,639. �. HYANNIS, MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT l kkikot sm5-727 XJ Name Dat a of T e In ction / O r to s tine L' Address Risjo ion S�_ ,, )- 4Level etail Previous Inspection Telephone ential 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: /�VIAV V Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. AL r 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 Q ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals r FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4.Food and Water from Approved Source ❑ 16.Cooking Temperatures L. ❑ 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 e PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) r ❑ 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. R ❑ 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. 6=One critical violation and less than 4non-critical violations re 9 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 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 ( )( ) 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. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 t0 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.Dumps r 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 'sLg tore Pnn. Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Y Dumpster Screen? 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 Law Cooled to 41°F/45°F Within 4 Hours* ( ) g 14 Food or Color 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 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* g * 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* - - * P g 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 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 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 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. 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,Meals&Game Pathogens* Effe cn�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 40L11(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* 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* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3 403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL'PRACTICES * 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity g g 3�03.11(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 3-403.11E Remaining Unsliced Portions of Beef Roasts* ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 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 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 1 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. ro TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Page: of A- OFFICE HOURS A Eo PUBLIC 2 0 MAN STREEETHEALTH SION 3::30--4:3:3 P.A.M. 0 RM. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �A ,63. `0$ HYANNIS,MA 02601 soa-s2�Rsaa No Reference R Red Item PLEASE PRINT CLEARLY I. ,EOMP,s FOOD ESTABLISHMENT INSPECTION REPORT AA Name IAI Da Type of Inspection / wn outine i t Address Risk rvi ection Level Zet.:i Previous Inspection Telephone ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint i 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. ; eq 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) ❑ 'y i� 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 ❑ 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 B=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 )(590.005(FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxic Materials (FC-7)(590.o08) 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 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' Sig atur Pri Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N 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* PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Sutiitances 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* g g * 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 7-202.11 Restriction-Presence and Use*of A Food Employee or An 3-302.15 _ Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Requirements 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) 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 Reared or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 1590.003(E) Removal of Exclusions and Restrictions g � ) Disposition of Adulterated or Contaminated Food - 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Tem erasures* Raw Seed Sprouts Not Served y * P 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-Served* 3-201.13 Fluid Milk and Milk Products 4-501.112 Mechanical Warewashing-Hot Water Monitoring 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. 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* Efferriw 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-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 StuffingContaining Fish,Meat,Poultry or g 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* in mobile food,temporary and residential SuuPccs 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* foodborne illness interventions and risk factors. * 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. radicsshould be debited under#29-Special 5 Receiving/Condition 2 401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 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) •4i 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* 1g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 3-501.14 A 3-202.18 Shellstock Identification Handwashing Facilities ( ) 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 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. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S.590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. RD T Da®R 1k" NA/PIA PPiwG O Rbom �aTRaoKi c0 DOOR% Nprth Atlantic Region _ Weighted Items Only MEAT DEPARTMENT PLU LIST CHICKEN WINGS TERIYAKI CHICKEN WINGS BUFFALO STYLE CHICKEN WINGS HONEY JALAPENO BARBECUE Honey buffalo chicken wings Garlic teriyaki chicken wings Chinese bbq wings Sweet bourbon chicken wings Sweet and spicy chicken wings Pixie dust chicken wings Chick Magnet chicken wings CHICKEN WINGS HONEY JALAPENO BBQ FAMILY PACK CHICKEN WINGS BUFFALO SPICY FAMILY PACK PORK SAUSAGE SWEET ITALIAN FAMILY PACK CHICKEN BUFFALO WINGS TERIYAKI FAMILY PACK � ;•,c� -X"�.,,��'*�}. M�a�t naf�ed Chf�'k'zw'Br�eas',. T�� 'Y-�-� ''�"T 4 [CHICKEN HICKEN BREAST BONELESS SKINLESS HONEY BOURBON HICKEN BREAST BONELESS KOREAN SESAME HICKEN BREAST JAMAICAN HICKEN BREAST BONELESS TERIYAKI BREAST GARLIC HERB CHICKEN BREAST PESTO CHICKEN BREAST HONEY GINGER SOY CHICKEN BREAST BONELESS LEMON HERB CHICKEN BREAST BONELESS BALSAMIC VINAIGRETTE CHICKEN BREAST BONELESS HONEY JALAPENO BBQ CHICKEN BREAST BONELESS LIME CHIPOTLE CHICKEN BREAST ORANGE THYME CHICKEN BREAST BONELESS SANTA FE CHICKEN BREAST..BONELESS CORDON BLED_:,,.... ..:: , .-.,. . .,.:._,.__-_ ,.... _.:.._.... . __. .__..... . . .._.. .. .........__-_- CHICKEN BREAST BONELESS GARLIC HERB CHICKEN BREAST MARINADE r Garlic teriyaki boneless Breast General Tsao bonless breast Sweet bourbon boneless breast Maple chipotie boneless breast Carolina bbq boneless breast Mesquite bbq boneless breast Rasbeny chipotle bonelss breast Lemmon pepper bonless breast Sweet and spicy bbq boneless breast chick magnet boneless breast pbde dust boneless breast BBQ Rubed bnls breast ORANGE GINGER BONELESS SKINLESS CHICKEN BREAST `Chicken Partko Collets ` GARLIC PARMESAN PANKO CUTLET MOROCCAN PANKO CUTLET HONEY MUSTARD PANKO CUTLET SUNDRIED TOMATO PANKO CUTLET HONEY ORANGE ROSEMARY PANKO CUTLET North Atlantic Region Weighted Items Only MEAT DEPARTMENT PLU LIST a ...sic.`. ,�.�'�1T��r3.K.._...�:.»� �S..�-�'�r'a•:s..,�=z BEEF BRISKET WHOLE CORNED GREY BEEF BRISKET CORNED FLAT CUT GREY BEEF CORNED BEEF BRISKET FLAT CUT BEEF BRISKET GREY POINT CUT CORNED BEEF BRISKET POINT CUT CORNED WITH PICKLING SPICES BEEF CORNED GRASS FED BEEF ROUND CORNED BEEF STEAK TIPS SWEET BOURBON, BEEF STEAK TIPS MARINATED BEEF STEAK TIPS TERIYAKI BEEF STEAK TIPS SANTE FE BEEF STEAK TIPS KOREAN SESAME j BEEF SIRLOIN KABOB THEO'S STEAKHOUSE BEEF TENDERLOIN TIPS THEO'S STEAKHOUSE BEEF SIRLOIN TIPS GINGER GARLIC Garlic teriyaki steak tips Maple Chipotle steak tips Lemon pepper steak tips Mesquite bbq steak tips Pixie dust steak tips Cow bell hell steak tips �n- LAMB LEG GREEK STYLE. LAMB LEG BONELESS HERB CRUSTED LAMB LEG GARLIC AND HERB LAMB LEG ROSEMARY MINT&MARJORAM LAMB STEAK ROSEMARY&MINT Souvlaki butterflied Iamb leg LAMB RACK ENCRUSTED LAMB LOIN CHOP ROSEMARY&MINT 1 LAMB RIB CHOP ROSEMARY&MINT LAMB LOIN ROSEMARY MIDIS.&MARJORAM NEW ZEALAND LAMB LEG MEDITERRANEAN LAMB RACK DIJON HERB CRUSTED v- ,wPork�Yrepered foods Corned st louie style ribs Sublime swine boneless pork butt Pixie dust boneless pork butt sublime swine st louts rlbs Pbde dust st louts dbs Sublime swine country style ribs Garlic teriyaki petite pork loin General Tsao petite pork loin Chinese bbq petite pork loin Pixie dust petite pork loin Sublime swine petite pork loin COFFEE RUBED BONELESS PORK CHOP COFFEE RUBED BONE IN PORK CHOP 10/25/2017 What you need m know about VuoMaater,BPm FDA anumSF Standards'Vuowaote, ` - �� U 0�~�� _~ . . ��»� nx—»�� u �� = �� PRESERVE YOUR GAME HUNTING AND FISHING FRESH BITES BLOG RESOURCES CONTA( Home / Fresh Bites B|og /VVho1 you need to know about Vack4aate[ BPA' FDA and NSF Standards Wnncaht you need to "Knowabout VaG--=,M4o%!S2b)ter, BPA, FDA do% ndn NSF ISO q a n d(oat% r d'.S 18th Feb ��y�— �«Th8\��@Ster�`Te8n& ' .. ' � / � ' 10/25/2017 what you need to know about VacMaster,BPA,FDA and NSF Standards-VacMaster r 4 d t-Rtl1UD FL r 1yr/ ,[ II Some of our most frequently asked questions come from those in the food industry, seeking to remain in health department compliance. These questions often revolve around a few familiar acronyms to restaurant and food centered businesses: BPA, FDA, and NSF We take great pride in the quality and safety of our products, and want to be sure that this information is readily available and easy to find. You can continue reading for the answers rounded up in one place, or check out the Help Center if we missed one. Of course if you can't find your answer we encourage you to Contact Us and we will be happy to help. 1. BPA It is important to make sure that the products coming into contact with your food are free of BPA's, phthalates, and other plasticizers. Yes ALL VacMaster bags and pouches are BPA free, also free of phthalates and other plasticizers. 2. FDA 10/25/2017 What you need to know about VacMaster,BPA,FDA and NSF Standards-VacMaster Many vacuum sealers and bags are used for food packaging purposes, making compliance with ;the Fdod and Drug Administration standards important to consumer safety. Below you will find VacMasters Certification and Guarantee of Compliance to FDA standards: n . January 112014 Food Manufacturer's/Supplier's Certification and Continuing:Guarantee Under the Federal Food,Drug,and Cosmetic Act The articles comprising each shipment or delivery hereunder made by ARY,1nc. are hereby guaranteed as of the date of shipment or delivery to be on that date: a) not adulterated or misbranded within the meaning of the Federal Food,Drug,and Cosmetic Act("the FDCA"),as amended(21 U.&C. §301 et sea.)-and b) not adulterated or misbranded within the meaning of any state food and drug lady,the adulteration and misbranding provisions of which are substantially similar to those found in the FDCA,and c) free from microorganisms that may produce food poisoning or other disease in humans;and d) in compliance with applicable current Food and Drug Administration regulations, guidelines,and action levels for poisonous or deleterious substances, including those applicable to contamination with aflatoxin and other natural toxins;and e) in compliance with applicable current Food and Drug Administration regulations, guidelines,and defect action levels for natural or unavoidable defects, including those applicable to contamination with pests,undesirable microorganisms,and extraneous material. This guarantee is continuing and shall remain in full force and effect until revoked in writing. This letter can also be found here in the Help Center. 3. NSF 10/25/2017 What you need to know about VacMaster,BPA,FDA and NSF Standards-VacMaster Our machines are not meant to come in direct contact with any food item, as such they are NOT NSF ,,certified; however, as food will only come in contact with the bags, which are FDA approved the units are ideal for restaurant and other food industry use. Tags: Bags and Pouches Chamber Suction Bags and Rolls Share: G+ f 0 1 t7 in f' VACMASTER The Professional Way to Prep, Cook, Package! 800-821-7849 Navigation Preserve Your Game Hunting and Fishing Fresh Bites Blog Resources - Contact Us Help Center Gift Cards 10/25/2017 What you need to know about VacMaster,BPA,FDA and NSF Standards-VacMaster Categories o Vacuum Sealers Bags & Rolls Accessories & Parts Sous Vide Outlet Stay Connected f V ® G} Subscribe I s` x YOURNAME@EMAIL.COM VISA DISCOVER L I T Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BAPNgrAB , : Paul J.Canniff,D.M.D. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 764 Issue Date: 12/10/2019 DBA: FANCY'S OWNER: OSTERVILLE MARKET PARTNERS, INC. Location of Establishment: 699 MAIN STREET OSTERVILLE, MA 02655 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean,IRS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �"'F For Office Use Only: Initials: �. tea.$ Town of Barnstable Date Paid l � ''� Apt pd$�3 = • ,AaNeu Inspectional Services / t639.►`� Public Health Division Check# =(O Thomas McKean,Director L©�r �l3 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENTQ�rfi��i ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS:Q WELL WATER:YES NO (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO NUMBER OF SEATS: INSIDE: •— — OUTSIDE:—TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***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 Idtchen) 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 50"624644 nA A r..�...drMn A nn n rVc'iAi n A... 1W , OWNER INFORMATION: FULL NAME OF APPLICANT �1�1 SOLE OWNER: YES� OWNER PHONE ADDRESSC�ZIv�- CORPORATE OWNER L-1- � tx,, CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: \ List(2)Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **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 1p/ 1q /,262f) 1. C`��z or �� 10/ .2& /lC-Q4 as/�29 SIGNATURE OF APPLIC DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to onenine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please can 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 httu://www.townofbarnstable.us/healthdivision/apalications.aso. 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. Iy � 'oFTwe For Office Initials: Town of Barnstable Date Para la Amt Pd$ BARNSTABLE, : Inspectional Services MASS. 'g Check# i6'9 ,� Public Health Division Arfp�p Thomas McKean, Director 2,13119 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE DATE ( I t NEW BUSINESS OWNERSHIP RENEWAL to' NAME OF TOBACCO ESTABLISHMENT: ;�7O ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: F C'C=+ram TELEPHONE NUMBER OF TOBACCO ESTA"9NT: = OWNER'S NAME: _ � ,r OWNER'S PH#(Io[\7) OWNER'S ADDRESS: CORPORATE ADDRESS: f��t !Z l :!k—�.-4, csaLbVCORPORATE FID# ANNUAL: � SEASONAL: DATES OF OPERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE CODE/NIA 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•//malegi slature.g-ov/Laws/GeneralLaws/PartIV/TitleI/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License t Se I Ci ars and S g Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: �. . DATE: 1 R/ LAC( C( Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc ESTABLISHNNNT'S N TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one(21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—&371-9.Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: A,VVIL , -:Yo—am \_ ►ature Printed Name Date z oil Signature Printed Name Date (OR&J-, L. I I - I-�'- n, M� C__%" OtA lure fed a Date Zoo QS Si afore Printed Name Date M C1 I I CI �` I I Signature Printed Name Date AALA H I c2k( r 1 y cl Signature Printed Name Date Signature Printed Name Date C:\Users\d=llik\AppDataU-ocal\Microsoftlwiudow,;\INetCache\ContencOutlook\YZOF4J38\TOBACCO APP2019 dob.docc Commonwealth of Massachusetts LetterlD.L095909542 4 Oy'�7 m Departmentot'Revenue Notice Date:September5,2018 Christopher C.Harding,Commissioner Account n):CGL-10216794.007 ti nf� mass gov/dor RETAILER LICENSE FOR SALE OF-CIGARETTES - OSTERVILLE MARKET PARTNERS INC o 1:ANCYS MARKET 699 MAIN ST OSTERVILLEMA 02655-1903 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(b 17)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 '�ttt sF MASSACRUSETTS DEPARTMENT OF REVENUE Forin CT 3T Retailer License for Sale of Cigarettes' ,Fn*ro�4 This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. OSTERVILLE MARKET PARTNERS INC Account ID:CGL-10276794-007 FANCYS MARKET License Number: 1525516288 699 MAIN ST OSTERVILLE MA 02655-1903 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 Commonwealth of Massachusetts Letter ID:L2106016394 Department oiRevenue Notice bate:September 4,2018 e - Christopher G Harding,Commissioner Account ID:CRL-10276794-010 In o4� mass gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO 11,11I1ui, ,rrllrltllrprtl�ltt�lu�t�illilr1igt�lptle��tlE, - - o OSTERVILLE MARKET PARTNERS INC ® FANCYS MARKET 699 MAIN ST OSTERVII.LEMA 02655-1903 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(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 -------------------------- -------------_-----------------------+_-- --------------------------------_._._.-------___------------_ MASSACHUSETTSDEPARTMENT OF REVENUE Farm CT 3T c Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. OSTEkVILLE MARKET PARTNERS INC Account ID:CRL-10276794-010 FANCYS MARKET License Number:386584576 699 MAIN ST OSTERVILLE MA 02655-1903 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 far failure to comply with state laws and regulations. Effective Date:October 1,2018 Expiration Date:September 30,1620 Oti Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. WAULL, Paul J.Canniff,D.M.D. KASM MA 02601 F.P. Thomas Lee Alternate 200 Main Street, Hyannis, 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: 764 Issue Date: 1/1/2020 DBA: FANCY'S OWNER: OSTERVILLE MARKET PARTNERS, INC. Location of Establishment: 699 MAIN STREET OSTERVILLE, MA 02655 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 G?, Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY I _ JOp THE rp TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Page:. of o OFFICE HOURS BARNSTABLE. PUBLIC B200 MAN SH EET 3:30-4:30 R P.M. SION : 0- :30'A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION' Date Verified MASS..eam HYANNIS,MA 02601 oe-862 4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPE N REPORT Q Name ➢ , Date e o Tvoe of Inspection _ Routine 01 "AGO H S Af(� Address Risk Food Servi Re-inspection Level Previous Inspe ' Telephone Residential Kitchen Date: I /' obile Pre- / '� Owner HACCP Y/N //'� emprary Sus ec ttsrer General Complaint Person in Charge(PIC) Time k t ed Break-fast HACCP Aq Other Inspector 1-2m _ Each violation checked requires an explanation on the narrative age(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 �7 ❑ 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 NU 1W ❑ 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 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 ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. 1AD& ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in.an F. 25.Equipment and Utensils FC-4 590.005 B=One critical violation and less than 4non-critical violations 9 ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or-insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to a non critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. IMtakon,4 to 8non-critical viol dons-;Ic. 30.Other DATE OF RE-INSPECTION: I cto ign ure nnt: 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 -' V 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 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 P g Require Reporting by Food Employees and Contamination from the Environment I 3-501.16(A) Roasts Held At or Above 130°F* _ � 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 590.004 11 Variance Requirements 590. 3(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* ( ) q 00 Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ( ) - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts'Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 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,Meals&Game Pathogens* effe cn�innom 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 _ 3-401.1I(B)(1)(2) Pork and Beef Roast-130'F 121 min* Eggs* 4=702:11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sourcos* 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* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11. Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* * (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 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 3-501.14 13 Handwashing Facilities g(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. * 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 I 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1 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 Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. BARN ABM John T. Norman !d1l F.P. Thomas Lee Alternate �ajg• �� 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: 764 Issue Date: 12/20/18 DBA: FANCY'S i OWNER: OSTERVILLE MARKET PARTNERS, INC. Location of Establishment: 699 MAIN STREET OSTERVILLE MA 02655 Type of Business Permit: FOOD SERVICE 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, IRS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: of HE ray For Office Use Only; Initials: 1 o Town of Barnstable Date Paid a Amt Pd$ BAMNST" Inspectional Services �� eTFD�`�A Public Health Division Check# Thomas McKean, Director o45i 11� 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A- FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: �C—N4nt-� �-�-caxx� c ADDRESS OF FOOD ESTABLISHMENT: 1pGl�_ �«�n "l \S�l�l±., 1MA C'—''a�— MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT:J�1-62(? - TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO_. (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: /_/ TO NUMBER OF SEATS: INSIDE: ':-- OUTSIDE: TOTAL: ' SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***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? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)9 TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) V FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) 5 *** SEASONAL,MOBILE &NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FormsTOODAPPREV2018.doc i PLEASE CALL 508-8624644 OWNER INFORMATION: ` FULL NAME OF APPLICANT \Y� SOLE OWNER: YES/0 OWNER PHONE# 7 ADDRESS urA��.\r —�C.1 SAVE-, X CDZ CORPORATE OWNER- � `--i �s CORPORATE ADDRESS: c:�`Y1 PERSON IN CHARGE OF DAILY OPERATIONS: vw L -S -)�Cjxr\ t-. 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 AUeurgen Awareness Expiration Date 1 L4 r� SIGITATURE OF APPLIC DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments;including mobile trucks must be inspected by the Health Div. prior to oeening!! Please call Health Div.at 508-8624644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at htta://www.townofbarnstable.us/henithdivision/aaolications.asu. 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.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1 st. n..•__c__.:__r__...rnnr�•nnnraron.o�__ Town of Barnstable =: Regulatory Services Department BMWSTABLE 9� ";& �0� Public Health Division '°rEc 39. 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Y 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 ` - LAST NAME OF APP T FIRST NAM MIDDLE INITIAL STREET ADDRE TELEPHONE # FID# Do you currently possess a state license to sell tobacco products? Yes V/ 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 prov'ded_on the next e). Each employee who sells tobacco products must sign the E , e�Signat a orm (provided herein). Signat re Date Q:\Application Forms\TOBACCO APP2018 dob.docx i Establishment � TOBACCO SALESc�- ri - Employee Signature Form �. This form is for official use to indicate that the employee(s) of this establishment received and understood sections VII b. and VII c. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of eighteen(18). Below are sections V11 b.and VII c.of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file,in the office of the employer and retained. Such signed forms must be made available for inspection,during the license holders normal business hours upon request of an agent of the Board of Health. e. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age,the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIlb. and V11c. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Si lure Printed Name Date -rl Ct,C" l® 3 1 Signature Printed Name Date acqAl —��e , Printed Name Date Signa e Printed game Date Shure Printed Name Date jjd� " 6� r 'I ; y 1 � d Signatur ' ' Printed Name Date 6 A?- Signature Printed Name Date C:\UscrsidecollikiAppData,Locai\Mimso8\wiudowsllNctCache4ConteuLOudook`,7NTC680MTOBACCO APP201 R dob.docx L C.wr /l THE , Town of Barnstable Initials os Date Paid Amt Pd$� Inspectional Services Check# �BA` �� Public Health Division 200 Main Street, Hyannis MA 02601 . Office: 508-790-4644 Thomas A.McKean,RS,CHO x FAX: 508-790-6304 Director of Public Health Fee: $85.00 63 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 ESTABLISHMENT NAME (DB/A) ,n�,,jS �— � h�� '� 6 z C ADDRESS OF BUSINkSS MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OWNER'S NAME: FIRST DLE EMAIL PHONE# FEDERAL ID# Do you current possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive 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 roducts must s' the Employee Signature Form (provided herein). / Signature Date Q:\Application Forms\TOBACCO APP2019 dob.docx � r a "w r L ESTABLISHMENT NAME TOBACCO SALES Employee Signature Form < This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors— 4 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: 67—) /4'k Signature Printed Name Date Si ature Printed Name Da Signature Printed Name Date Signature Printed Name Date � C U rr�h Sidnature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP2019 dob.docx MIS 'dh1,4d }.r3 a 4. �rf�a �r8 # s r& i71' krr t 'S"eta3t ,r�r J j} ! Ea wlfN� rr h'jf (r Y:s. a gkrt'„ {y„'" s rp E+ .� � ,;!,. � 1i� 1f'km'i -';4 wsd '- tb✓'"'b �.jy r;, '., a x yF 1+'r'tt{ �y 1.51 j' .- A. y v4P It t r 1 �;:y; }pry y m. t{(G r 'Ty'y.. 1 t 5 p;yY //��/ kh�i� !.�` x a r }. x lrg a3 �5t rfri� X z 'f i "1 rA 5�'#�.a'�EriitY - - i•i ..i. . . lff°7h'aykfiW.& Deli Q .x 4 r�7rrt. 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Q" served with a:cu}m.amonty onogurt dipptg >$a�tce k3`§�6 ®rS d of j 1'7r�� $ /$65` n ` fp _ �, ,"a 3J £`k ta:e",k}� s,.y�r• '� ' gip xP _ r Bite Size`Lump�Crab Cakes w/Parsley Capers3Tarr Sauce 45 ?; @NrFa�rvtrrlldle " -/ `r f ' "' "' frre`sh ve stables serveds s � ' Pan'celtaCnsps ytf/Goat Cheese&Pear Sesame Won Tnn 't a gat aspYmont oP g Triangles is `,tt r ° }t� our choice of herb or lileu cheese dip ' ' ; <:; topped w/Smok ed Salmon 8LwWasabi`Cremea�y w� • Old-fashioned Family Service Kim Fr } �. qSavo Cream Puffs filled withLobster Salad crab&e Chef Prepared Meals Soups Sandwiches i j� .'. .a*�. ,ti r �`�enderloin Platter ..rs ,2 ,s. iF ry z�<E S das,'"ig7 2 M�, ;f=.``{' }Sliced roastedrtenderlom;of beef servedwi your ,>)�' t Avocado Salad or�Cltcken Salafl�^ i t`h'Q re of lio eadish'cream or blew cheesesauce r Fully Staffed Meat & Kitchen Depts. ' �+r::�',r r; , `-" €:-`" ° "'` .;st t�;}?" ,,i ''COstlnl.tU ed,w/T'enderloin of:Beef&Caramelized�0 ion; $80/$�30/$1$0 ;,s 5, pp r T� Fresh Baked Goods • Fresh Flowers o � e t '7 ( Sl> t"?s'a` d 7'' � Mediterranean Platter r Chicken Cashew Spri ng Rolls t' isfs r kr lea Fresh Local Produce }S Hummus,Taboulleh grilled vegetables ohves and _Tequila Gulled'Shrimp x of en roasted tomatoes served with gelled pi{a brread! ;y y� ay} Beer, Liquor &Wine 7 `rr ' $35/$55/$75 r Z � Orange Glazed Grilled Shrimp , ,t �t'mot j (case pricing on wine) Best Butcher Shop 4' s'r Crostuu Platters{ Border Tarts South of:the An,assortmeht.of,.3 d>gerent crostuu,:Goat.cheesevv�th oven roasted tomato and Ch 4:,KE ti icken'Satay,Skewers' !� b curved clucten salad and,tenderlom of beef wtth.caramehzed onion '7 zarella Tomato Grilled 35 45./., 60. Fresh Moz, . ' t stem Artichoke Heart Skewers .tale n pe ,off: ,r fl Bernardo's'.Antipasto mouth watenn assortment of I 115t Upl Qa "B� L , Abed of}Romame:and field lettuce topped with a , g Itahan;iiieats&cheeses grilled asparagus grilled ctppohri(omons roasted red ,,Peppelpe oven roastedaomatoes,:olives,marinated mushrooms and;g►llled Entr -e I U fern aln y °' O� S artichoke hearts;Includes crusty bread and our own vinaigrette for'drizzhng n r11aSSQr n- rn► 1 1 Chicken or Veal:Piccata w/Lemon Caper Sauce w s� $55/$75/$95O8 -6 Poached Salmon w/Hollandaise Sauce Grilled Tequila Shrimp Succulent Tequila Marinated Grilled Shrimp(4 per person), I Grilled Swordfish w/Lemon Basil Sauce ` served with our avocado,lime,cilantro dipping sauce $40/$65/$85 I Roast Tenderloin of Beef wrnort Wine& ! 699 Main Street, Osterville Roasted Shallot Sauce Fancy's Tasting Platter A delicious assortment of dips,cheeses,olives,summer sausages and a few sur- prises.Perfect before dinner or on the boat I -6954 $45/$65/$85 Mediterranean Shrimp Tenderloin of Beef Stroganoff FREE DELIVERY DESIGNED,PRINTED&DELIVERED BY i GATEHOUSE MEDIA(508)375-4930. 111, .S1f, Y J, f r ). d"_`r{ r�7 r ;.Y`jar - r '.,"1 r f p `N. 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Yl,,.�. �. 1 7 F a :�T�,i.. .�!„:,x r PY.. : vfb8 `J�9t ;,,Jy.S, r �'n.'i 2 R-,,.o;,,a stBeefFClub� - ,,.:,..- �, 1 .f5,} Ft s }fl 4•p7fr tP�, �i�t;,,'ty6.' t. i:.s � -7 { r..�,.i `��a�,ndf ,.ET�, Burger sT c'",•+. r $b50 >:S B ef,. a o; can.• Ba n..L<,ttuce!'Toma 1,A #Roast a ,M y Amen Cheese co e r , r r +,� � {+ r Certified Angus Beef Patties Light7&F>cesh Grilled Chicken i, ' '•'rt t�i :'fit' �IEC1� t MGa�+ lattC r f .75 or 2 for$5 +tax Y � $2 Grilled Chicken Grilled Aspara4gus` Sweet Peppers Lettucer and Featuring Boars Head meats Black Forest loam'React Beef Hot Do I Low Fat Roasted Garlic Mayo r 7a{ Turkey YItahanxHamt Salami and Sliced Cheese Boar's Head Super Size Beef Do Calcutta Includes Rolls P g Turkey Jack\Che ese;Shr edded Carrots;Cuciimlers Sweet Small$55/Medium:$75/I ergs$115 $1.75 or 2 for$3 +tax Peppers Red Onion and our Spicy/Sweet Cuny Chutney Spread Soup of the Day J. w Always Kitchen n' sp 'urket' wa s Made in Our $3.70+tax Meatball Sub Just like Mama made! i , I • a ery � tC �,r _—__• DESIGNED,PRINTED&DELIVERED BY 508-428-695 GATEHOUSE MEDIA(508)375-4930. .............................................................................................................................T�..............................................................................................................................................................................................-............................................................................................................................................ BioDiffuser Standard & High Capacity Chamber Specifications Chamber Height All three BioDiffuser sizes can withstand H-10 loads when Chamber installed with properly graded eat Chamber and compacted soils. A mini- Height mum of 12" of cover is required End for H-10 loads. The 14" High ' Capacity BioDiffuser is A.]. . designed for H-20 loads. A minimum of 18" of cover is At lEnclzou required for H-20 loads. o y, U wear;; ' cf Cafe Available Sizes 11" 14" High 16" High Chambers Standard Capacity Capac H-10 H-20 H-10 ADS Prod # 1100BD 140OBD D Lenqth 76" 76" 76" Width 34" 34" 34" Invert 6.5" 9" 11 .3" Units / Pallet 51 38 45 Units / TL 1071 798 945 IIII�� II � �IIII ADS / PSA BioDiffuser Chambers can be ordered in pallet quantities. Contact your ADS Customer Service for ordering details - 1-800-821-6 7 10 FAX NO. 508, 8887259 Feb. 25 2008J12:28PM P1 7q O Xkal* f 'mNGINEERING IT RESEARCH SERVICES FINAL REPORT Witness Testing: H-20 Lord Testing of the SloDlffusafrm 'IS' High Capacity (1600 BID) Leaching Chamber to IAPM0 Standard PS 63-2005 by Amy Harrison, Project Manager Engineering & Research Services NSF International Test Facility.- Gerken Residence V-138 State Route 108 Napoleon, OH 43545-9766 y Sponsor. ADS, Inc. 4640 Trueman Blvd, Hilliard, ®H 43026 ,April 25, 2007 Hoped Murnber 070 ADS,Inc. Copydght®NSF Internalonal April 25,2007 FA 0 900�5 l a 6 nis report may not be distributed wftheut the written permisslon of NSF International Hx iv0. 508 8887259 Feb. 25 2008 12:29PM P3 representative observed at the open.end. The chambers werQ then uncovered and exposed for visual inspection. "Vesting Results: Bach evaluated section of the chamber retumed to its original geometry despite experiencing some clef lecdon during each pass at each test toad. There was no sign of damage or deformation to the joiner or center of the assembly upon Inspection. This Complies with the requirements of section 6,1.1 of the IIAPMO Standard. (Annex A Product Specifications MoDiffiaser'O At Grade System Detail 16" High Capacity Chamber nnzivc s�a�at d� IR ACB[®VEL FILL 1. LaCCCA/GTE TL's1uLrNd TQ Adl1PEQ 1fEP[H+eG WCLS=E 9Y C74TE Ann LCCRL CCtA. R, CNCOTH IRIFE6LILARLTLE4 10 THE COAVATtoN, A Lmn-FLAT Eas Ate=LalI.➢RCri - 1 4=016LC 310WRL6R LiACR=.C9..i+2mm ARID ' � WL51i7PL8i iNnIL.ATEff Tn6E7'IE¢Itl TR£NCHt6�. i. QJSTALL WiVCiZ:11L CC CAA Alm r=.LpX LID G1..dt��VL1H EADZF7ti, L PUMA dR Pipe HCILE'nP'O=M=HY rAs Ctm 3W RAM= An IrrW .01®COWAW LLET PIPE% i. FILL MEVfA.L AA£A TO Tf P CHMW=WIT4 1{mm =L CAI==0 aR rDE CMVCL NIW '.ii""cLCnL1lM WAW CLAY.=L.T,not WMIS 7. 'VrAlk nt,L7LL To CtUCVrCT GWL 1%.flnWFIjM am�63 OF ic• LOAD RATrRr. TWIG ti VMt [I@OICTawr TC ACHIEVE 9. GIZVOt MMIFF MR LUMMU L3I8N®4ffi Tf, 6 WI1QWW OF La- CMEZ ASJnm OR I ZEeWg W'CWVQt NA7VdN_ METH O CUMM I'CF IW WALL Z=w MLi. I 4if£'tSd' a Ra v Report Number 07/21 ADS,Inc. Copyright 0 NSF laternationar April 25,2007 i This rGPoK may hot be cflstributed without the written permission of NSF intemational 4 of 6 i •FAX aNO: : •508 8887259 Feb. 25 2008 12:29PM P2 ' �dSF Labsrnational a f d TFISting Org8fif ation: NSF International Phone: 734-769-8010 78a N. Dixboro Road. Ann Arbor, Ml 48105 To st Date: April 18,2007 Report issuance Date: April 25, 2007 I Ralz�ort ReWsion Date: N.A. Ofient: ADS, Inc. Phone: 614.658-0284 4640 Trueman Blvd, Hilliard,OH 43026 PVi5:tivot riptiorr: MOM userim 16"High Capacity(1600 BD) Leaching Chamber ,'cncl1 aging Surnr'I'rM: All portions of the test performed were under continuous and direct supervision of a representative of NSF international. This product complies with the requirements Section 6.1 of 1APMO Standard P`8 63-2005. Testing Witnessed By: NSF Representative: Date, Technical Manager: t�� Date' ICgj'% Uj i,iCANUR r d t:Iopbrt Number 07121 ADS,Inc. Copyright®NSF Internatlonal April 25,2007 �� .;Ik 90ti6035 2 of 6 This report may not be distributed without the written permission of NSF International i i COMMONWEALTH OF-MASSACHUSETTS EXECUTIVE OFFICE OF ENERGY & ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 0 DEVAL L.PATRICK IAN A.BOWLES Governor Secretary TIMOTHY P.MURRAY LAURIE BURT Lieutenant Governor Commissioner June 29,2010 Brian Smith F-+ d CD Fancy Market ads 699 Main Street t Osterville,Massachusetts 02655 1 r; p RE: NON-BO-I0-IVO03 7-17 ; Osterville-Fancy Market—Approval for Piloting Technology: SoilAir—Geomatrix,LLC DEP Facility ID: X230686 `.3 1 NOTICE OF NONCOMPLIANCE WARNING: THIS IS AN IWORTANT NOTICE.FAILURE TO ADEQUATELY DEAL WITH THIS NOTICE COULD RESULT IN SERIOUS LEGAL CONSEQUENCES. Dear Mr. Smith: It has come to the attention of Department personnel that you are in noncompliance with one or more laws, regulations, orders, licenses, permits, or approvals enforced by the Department. Attached hereto is a written description of.(1) each activity referred to above, (2)the requirements violated, (3)the action the Department now wants you to take, and (4)the deadline for taking such action. An Administrative Penalty may be assessed for every day from the date of this notice that you are in noncompliance. Notwithstanding this Notice of Noncompliance,the Department reserves the right to exercise the full extent of its legal authority in order to obtain full compliance with all applicable requirements, including but not limited to criminal prosecution, civil action, including court-imposed civil penalties, or administrative penalties assessed by the Department. This information is available in alternate format.Call Donald M.Gomes,ADA Coordinator at 617-556-1057.TDD#1-866-539-7622 or 1-617-574-6868. MassDEP on the World Wide Web: http://www.mass.gov/dep �w1 Printed on Recycled Paper Notice of Noncompliance o NON-BO-10 IV003 Title 5—Fancy market-SoilA'.r site piloting approval 6/29/2010 Page 2 of 5 If you have any questions,please contact Sanh Tran, of my staff, at(617) 556-1036. Sincerely, J David Ferris,Director Wastewater Management Program Cc; 1 Barnstable Board of Health; Wayne Miller, MD 200 Main Street, Hyannis, MA 02601 2. Peter T. McEntee,Engineering Works, Inc 12 West Crossfield Road; Forestdale,MA 02644 3. DEP-SERO Brian Dudley; 4. David Potts- Soil Air-Geomatrix,LLC 114 Mill Rock Road East, Old Saybrook, CT 06475 Notice of Noncompliance—NON-BO-1C-IV003 Title 5—Fancy market-SoilAir site piloting approval 6/29/2010 Page 3 of 5 NAME OF ENTITY IN NONCOMPLIANCE: Brian Smith Fancy Market' 699 Main Street Osterville, Massachusetts 02655 DATE WHEN NONCOMPLIANCE OCCURRED OR WAS OBSERVED: December 4, 2009/ongoing DESCRIP'T'ION OF NONCOMPLIANCE: Non compliance with 3'.0 CMR 15.285 and 15.287 and the terms of the Department's Piloting Use Approval dated December 4, 2009 for Fancy Market, 699 Main Street, Osterville, Massachusetts. DESCRIPTION OF THE REQUIREMENTS NOT COMPLIED WITH: 1. Title 5 at 310 CMR 15.024 provides: "It shall be a violation of 310 CMR 15.000 for any person to (1) construction or use of a system in any manner that is not in compliance with an applicable Disposal System Construction Permit Certificate of Compliance, or pp p Y p the terms and conditions of any other approval or order issued by the local Approving Authority or the Department" 2. The Approval states in item 4 "Within 30 days of the date of this approval, the System owner and the Company shall submit to the Department and the BOH an Operation& Maintenance (O&M) manual and Contingency Plan for the System providing detailed operating instructions for the System and procedures to be followed in case of a System failure or alarm event, including corrective measures to be taken and procedures for notifying the BOH and the Department within five days of an alarm event or equipment failure." 3. The Approval states in item 5 "In order to evaluate restoration of the infiltrative capacity of the soil absorption system (SAS), a minimum of two (2) additional observation ports must be installed within the SAS to monitor ponding levels. As-Built plans shall be prepared within 30 days of the date of this approval and submitted to the Department and the BOH.showing in detail all changes to the entire septic system. A copy of the plans must be kept on-site at all times". 4. The Approval states in item 6 "The System owner shall submit to the Department and the BOH a copy of the initial inspection and sampling agreement with the Notice of Noncompliance—NON-130-10 IV003 Title 5-Fancy market-SoilAir site piloting approval 6/29/2010 Page 4 of 5 Company or its designated contractor, including a sampling schedule". The Approval also states in item 8 "Throughout its life, the System shall be under an O&M agreement. The initial agreement shall be for 18 months, subsequent . agreements shall be for no less than one year. For the first 18 months of operation, or its designated contractor shall provide O&M services for the System. The O&M agreement required by this approval shall provide that the operator is an appropriate Massachusetts certified operator, or operators as required by 257 CMR 2.00, has received training provided by the Company, and is competent in providing services consistent with the System's specifications, with applicable operation and maintenance requirements established by the Company and the System designer, and with any applicable requirements established by the Department". 5. The Approval states in item 7" The System owner shall have the System maintained in accordance with the O&M manual and must submit a copy of the DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems and the SoilAir Technology Inspection Checklist to the Department and the BOH within 45 days of each inspection." DESCRIPTION OF THE ACTION TO BE TAKEN NOW AND THE DEADLINE FOR TAKING SUCH ACTION: Within thirty(30) days upon receipt of this document,the owner shall submit all necessary items described in 2, 3, 4, and 5 listed above to the MassDEP and the local Board of Health. Upon receipt of this notice the owner shall operate and maintain the system in accordance with the technology approval as referenced above. Information regarding the MassDEP Title 5 Innovative Alternative program can be found on the MassDEP web site at http://www.mass. og v/dep/service/regulations/310cmrl5.pd£ The required submittal shall be sent to: David Ferris, Director Department of Environmental Protection Wastewater Management Program 50"Floor One Winter Street; Boston, MA 02108 f Notice of Noncompliance—NON-BO-10 IV003 Title 5—Fancy market-SoilAir site piloting approval 6/29/2010 Page 5 of 5 I DATE: 2-11 B (D David Ferris, Dire for Wastewater Management Program CERTIFIED MAIL NO.: EXCERPT FROM THE BOARD OF HEALTH MEETING MINUTES FROM 8/24/10: B. Winston Steadman II represents Brian Smith, owner— Fancy's Market, 699 Main Street, Osterville, Map/Parcel 141-011, proposed change from Soil Air to Sludgehammer installation to assist the septic system — not required for the treatment of water. Winston Steadman 11 was present. The owner would have liked to continue using the Soil Aireator and the maker of the Soil Aeriator did not want to do an O & M and, without the pilot program continuing (due to cost), they are now applying for the use of a Sludgehammer. Sludgehammer is going to enter the air into the system as well and will use a high and a low vent to aid in this and should work better. The flow is only at 440-490 and they have a high concentration with the creams, etc, being used. This will be addressed by using the Sludgehammer and introducing air. There will be two additional filters added. Upon a motion duly made by Dr. Canniff, seconded by Mr. Sawayanagi, the Board voted to approve the plan dated 7/27/10 using the Sludgehammer with the following conditions: 1) done in accordance to the specifications listed in the MASS DEP approval letter of Sludgehammer for Remedial Use dated August 4, 2009, and (2) an O&M be filed with the Public Health Division, 3) quarterly monitoring in the SAS for depths of ponding and if ponding continues to be equal or greater to original state of ponding over the first three months, the Sludgehammer shall be removed. (Unanimously, voted in favor.) July 9,2010 David Ferris, Director Department of Environmental Protection Wastewater Management program 5"' Floor One Winter Street, Boston, MA 02108 RE: NON-BO-I Ostervill —"Fancy.MaFket-. proval for Piloting Technolo Soil Air—Geo trix for Piloting DEP Facility ID: 6 Dear Mr. Ferris, Thank you for your letter of June 29, 2010. Please be aware that I have decided to withdraw from the piloting program at Fancy's Market,699 Main Street,Osterville, MA. I think withdrawing from the process is in my best interest to avoid legal consequences. ' ` The temporary SoilAir unit has addressed the ponding conditions in the leach field. Consequently,the use of this technology is not presently being utilized. In addition,the requirements concerning follow up testing and data collection are simply getting too expensive for a small independent entity. My goal was to correct the slow drainage in a brand new leaching field. I am not interested in demonstrating that an alternative system is suitable for general use. In hindsight, I should have chosen a less complicated avenue to correct the problem, but the Soil/Air technology.has given me great.insight into`what works.Should the need arise,we have hired All Cape Environmental to investigate technology that has already been approved by the state,and generates aerobic bacteria such as the approved SludgeHammer system.We are also planning to take advantage of commercial size outlet tee filters for each of my exterior tanks(grease trap,septic tank and pump chamber)to decrease suspended solids from reaching my leaching facility. We appreciate the MADEP's assistance with this pilot project in finding a solution to this matter. Please feel free to contact me if I can be of further assistance. S' cere`�c, T y a _77 Briainitk h Cc: Barnstable Board of Health;Wayne Miller, MD 200 Main Street, Hyannis, MA 02601 PeterT.-McEntee, Engineering Works, Inc 12 West Crossfield Road, Forestdale, MA 02644 s, DEP-SERO Brian Dudley David Potts—Soil Air-Geomatrix, LLC 114 Rock Road East,Old Saybrobk,CT 06475' ' Y ,y�'OFtOr DATE: L> FEE: * BARNSTABLE, • r MASS. 059.s REC. BY(-t4�-, Town of Barnstable SCHED. DATE: Board of Health /d 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne A.Miller,M.D. FAX: 508-790-6304 JunichiSawayanagi Paul J.Canniff,D.M.D. I Q yy� VARIANCE REQUEST FORM LOCATION Property Address: ` r`tAtN �r r C+�i �7t�1 V I Assessor's Ma and Parcel Number: P Size of Lot:Wetlands Within 300 Ft. Yes Business Name: �CG\t l 1 rM �-l/4{'�OX No :X— Subdivision Name: APPLICANT'S NAME: W►^ n9 A N 'Ir Phone Did the owner of the property authorize you to represent him or her? Yes X a No PROPERTY OWNER'S NAME CONTACT PERSON Name: I7c rI AN �yy►� 1- Name: L tI'a44e" At, -S"e& ,j Address: r�rojN d5lelVi 1�, Address: PO, 6Vx 93 cS ypl�6w51, iof -+g,0 Phone: 08� a� Got Phone:Ce bS, tZ a ►9 VARIANCE FROM pR,E�GyUL"A`TION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) Z A SysreM w.c�A�V'r�a� �N NCB. ��JSLatti,et` 'WD Ms N ...I G O � Z NATURE OF WORK: House Addition ❑ House Renovation ❑ Repair of Failed Septic Syste0p p -n Checklist (to be completed by office staff-person receiving variance request application) 1, D, Please submit copies in 4 separate completed sets. ao Four(4)copies of the completed variance request form —0 Z Four(4)copies of engineered plan submitted(e.g.septic system plans) : Completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or registered sari" Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request V--A f _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expen439for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/lessee only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne Miller,Chairman NOT APPROVED Junichi Sawayanagi REASON FOR DISAPPROVAL Paul J.Canniff,D.M.D. C:\Users\decollik\AppData\Local\Microsoft\Wirdows\Temporary Files\Content.Outlook\BAJ9P9B7\VARIREQ.DOC Internet e TRANS.NO.: CITY/TOWN: APPLICANT: FWC` "a 1VWV `io {A1I �'�— �j,9V�Q�jy�e�►je�.Jil�F1. ADDRESS: (OQq i "`t SI gee OS1 v ]1 t wrA, DESIGN FLOW: Al k gpd REVIEWED BY: 63104ev,3 A. (;k 44,%j X- DATE: 6�/ N/A OK NO VvNERALe"l Le al boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot,tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided 310 CMR 15.2204(t) Plan proper scale?(1"=40' for plot plans, 1"=20' or fewer for X components) 310 CMR 15.220(4)] Easements shown 310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for x upgrades]- if not, a variance is required 310 CMR 15.412(4)] Location of impervious surfaces(driveways, parking areas etc.) x 310 CMR 15.220(4)(d Location all buildings existing and proposed 310 CMR X 15.220(4)(c)] Location and dimensions of system components and reserve k areas. 310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(0] daily flow septic tank capacity (required andprovided) X soil absorption system (required andprovided) X whether system designed for garbage grinder X North arrow 310 CMR 15.220(4) Existing and ro osed contours 310 CMR 15.220 4 ( ) X Location and log of deep observation holes (existing grade el. on X each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h)and(i)] Location and date of percolation tests(performed at proper X elevation?) 310 CMR 15.220(4)(i)] Percolation test results match loading rate? 310 CMR 15.242] �C Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3)and 310 CMR 15.220(4)(n)] Address � 99 1" Ak%0 ':Za 0 qwV k 1� Sheet 1 of 7 N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply_ within 250 feet of the proposed system location in the case )C within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins �( located within 50 ft. 310 CMR 15.220(4)(1)] „ Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] if water line cross see 310 CMR 15.211 l) 1 Profile of system showing invert elevations of all system components and the bottom of the SAS 310 CMR 15.220(4)(0 Stamp of designer [310 CMR 15.220(l) and 310 CMR 15.220(2) Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3) Test Holes adequate(two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as x approved for an upgrade under LUA at 310 CMR 15.405(1) k Test hole adequate to demonstrate four feet of suitable material? 310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? k 310 CMR 15.103(3) Benchmark within 50-75'of system [310 CMR 15.220(4)( )] X Materials specifications noted? [various sections of 310 CMR 15.000 System components not>36" deep(unless Local Upgrade y Approval or LUA requested) 310 CMR 15.405 1(b)] (� 6qqAddress �' ° ��t l� Sheet 2 of 7 N/A OK NO Size OK? 310 CMR 15.223(1) Inlet tee located ten inches below flow line 310 CMR 15.227(6) �p Outlet tee 14" or 14"+ 5" per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)] X Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees(no less than liquid depth) 310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 X CMR 15.232(3) Three access covers(inlet and outlet must be 20" or greater) - middle access at least 8" (b 7/07) [310 CMR 15.228(2)] Access to within 6 "of grade -one port for systems<1000gpd, two fors stems>1000 gpd 310 CMR 15.22 8(2) All at-grade covers secured to unauthorized access? [310 CMR x 15.228(2) > 10 ft from building foundation 310 CMR 15.211 1) �C Buoyancy calculation Required/Done 310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211 Required when other than single-family dwelling or flow>1000 d 310 CMR 15.223(1)(b) First compartment 200%daily flow; Second compartment 100% daily flow 310 CMR 15.224(2)and(3) "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address l I 1 Mf�k N S6-etA— � �t� Sheet 3 of 7 N/A OK NO �% � ( N)f�OTIEiR '1GPC4 B�� 13�v��_ .,. ,,... .. .. ... ... .. .:. «, ..,.,., ... ....... .. . .. ..., ..ems , Located at least ten feet from any water line? [310 CMR 15.222(2) Disposal piping at least 18"below water line(when water and sewer cross, see 310 CMR 15.211(1)[11) Cleanouts required/provided ? 310 CMR 15.222(8) Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable x [310 CMR 15.222(6)] Proper pitch on all runs?(.005 within gravity-distributed trenches x and beds) [310 CMR 15.251(9)and 310 CMR 15.252(2)(c)] Siphonproblem/(leachfield below pump chamber) Endca s or vent manifoldspecified? X Size and orientation of discharge holes specified?(not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8)and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2)and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a) Riser if deeper than 9" [310 CMR 15.232(3)(01 9� Inside minimum dimension 12" 310 CMR 15.232(2)(b)] Minimum sum 6" 310 CMR 15.232(3)(e)] K Watertight cover if<2000gpd);waterproof manhole if>2000gpd 310 CMR 15.232(3)(d)] Capacity(emergency storage above working=design flow)? [310 x CMR 23](2)] Proper setbacks 310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE 310 CMR 15.231(5)] Service components accessible (not too deep with piping, X disconnects accessible) Alarm floats-alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. 310 CMR 15.231(6)and 8 ] Stable Compacted Base 310 CMR 15.221(2)] Buoyancy calculations/ l� �nAeeded ?Provided? }[3110LCMR 15.221(8)] Address 'O 1 "��' 5 �� Sheet 4 of 7 l N/A OK NO Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR x 15.240(1) Required separation to groundwater? [310 CMR 15.212)] Y. Aggregate specified as double washed 310 CMR 15.247(2) System Venting required/provided?(system under driveway or K >36" deep) 310 CMR 15.241 Inspection ports specified and within 3"final grade? [310 CMR 15.240(13) Breakout requirements met?(No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] ;ALE1 , 'ITS C$AsM$)�,R 1<5,,. �.,r,Yu I F Y Chambers and Gal. in trench configuration supplied with inlet every 20 ft. 310 CMR 15.253(6)] Each structure with one inspection manhole(if>2000 gpd must be tograde) [310 CMR 15.253(2) Aggregate 1'minimum-4' maximum. 310 CMR 15.253(1)(b) X 2' sidewall credit maximum 310 CMR 15.253(1)(a In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)] R Width 2' minimum 3'maximum 310 M CMR 15.251(1)(b)] 100 feet-maximum length 310 CMR 15.251 1 a Minimum separation 2x effective depth or width whichever X greater(3x if reserve between trenches) 310 CMR 251 1 (d Situated along contours [310 CMR 15.251(2) ��Breakout ��tOK? �[310 CMR .y�15.211(l)[41p and Guidance Document] � D" SAkJ(fi�atri�uml:sl2�Uf''bC( tE!t ..J.�{� '* , _,' '_' `," u,krni.>,a "t», �zrev„,� zU .,''!,:; minimum 2 distribution lines 310 CMR 15.252(2)(a Maximum separation between lines 6' 310 CM RI5.252(2)(d Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)( )] Separation between beds 10'minimum. 310 CMR 15.252(2) Bottom area used in calculations only 310 CMR 15.252(2)(i Address y ( ,'\��'" �� ""� © � l , Sheet 5 of 7 N/A OK NO Pressure Dosed System ? Provided pump and piping calculations as required 310 CMR 15.220(4)(r) ' Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system -make sure jet is directed as not to scour soil interface Guidance Document Inspections once per year(systems<2000 gpd) or quarterly x (>2000 d) good to note on plan 310 CMR 15.254(2)(d)] Construction in fill -Did the plan specify that the fill shall meet x the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? Guidance Document Impervious barrier installation must be supervised by k designer 310 CMR 15.255(2)(b) Retaining wall must be designed by Registered Professional X Engineer 310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? 310 CMR 15.255(2)] �C Breakout requirements met? [310 CMR 15.252(2)and Guidance Document At least 5 ft. from impervious barrier to edge of SAS (10 ft. X recommended) 310 CMR I5 255 2)(e �- Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface � Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP ApproLal Conditions? Is there a note on the plan regarding the requirement for x perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Hasa licant submitted a coy of a maintenance X 111 tiZC'£rS ram? uz Ws. rn. _ x.ram Are the variances listed on the plan ? [310 CMR 15.220 (4)( )] RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed - [Refer to 310 CMR 15.44144] Address l ` 1 � ,J 4�'IT b5 `� `� Sheet 6 of 7 N/A OK NO N o sett S',ensttrve` Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? 310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR x 15.216(l)] w �, Pumping to septic tank? 310 CMR 15.229 Shared System [310 CMR 15.2901 177-1 Address y I r"`�'�t � �i (( � Sheet 7 of 7 EXISTING 9�,....4 S N 97.24 X EXISTING SPOT GRADE 92 Oak Ln \ 96 PROPOSED CONTOUR 1 � —W— EXISTING WATER SERVICE -------:'; ------ EXISTING GAS SERVICE \, ,. � •; € ci �6.i A' � _ U.N.W. EXISTING OVERHEAD WIRES V 1'� 9 •�/1� /y = D o +� EXISTING WATER SHUT-OFF 'i,Z`•i\ O�1 \� � Main St EXISTING GAS SHUT-OFF 9� � 91TEST PIT BENCHMARK O( w0^no i'Ave LOCUS Rd I : 1 BLDG LOCUS MAP #707, O -per o 11 NOT TO SCALE dos �F 89 1 \� e c6 �t soc'� EX1SANG: 90IS �`6s�� BUILDING (#699) APN 1 41—012 9 1� \s�o TUF=95 10 j/ Sp �f �y �,o. .w...... 8so LOT A ... . .z _ NOTES: 7,486t S.F. / 1) OWNER HAS REQUESTED TO WITHDRAW FROM THE APN 141-011 ' �� TSITE HE SOILAIFI PILOTING PERMIT BY DISCONNECTING BLDG 98 0l T WATER METER MH 4 E 2 OWNER WISHES TO INSTALL A HAMM R. S ES LL SLUDGE HAMMER S 86 6 a _ ) � r #705 _G' `9r / �• �� FLOOR EL=90 34 1 i 1 E UNDER THE GENERAL APPROVAL. Qf 8 `DRAIN RIM EL 9015 : 3) ADDITIONAL SEPTIC SYSTEM MODIFICATIONS INCLUDE VENT e(6 ABU TT. SMH O� 1 / �'� ENHANCEMENT, NEW PUMP WITH TIMED DOSING AND INSTALLATION OF MORE AGGRESSIVE EFFLUENT FILTERS IN THE GREASE TRAP, SEPTIC TANK AND PUMP. �°� •� F j9 YS Q�p� V6 0 f VENT 1 '95,,49 "\ 9 S EXISTING DRY WELL \ PAR K G �. Z, 1. 4 / r 4 EXISTING SEPTIC TANK ADD ZABEL FILTER (MODEL NO. A1800) / -.\ ��,.� ",•<;'' ! I, EXISTING GREASE TRAP 00 ADD ZABEL FILTER (MODEL NO. A600) \ 2i ement BENCHMARK N0.1 CTR. MH ° e 9 ELEV:092.131NLET(ASSUMED) PROPOSED SLUDGEHAMMER INSTALLATION 6 699 MAIN STREET OSTERVILLE MA y; '0 o PROPOSED PUMP CHAMBER r ENT- _`Oc, °� (IN=86.08 RIMS, EL.=92.8t Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 . .... ........ ....._..... _....� "•. 0 Z INV. OWNER OF RECORD Engineering by: Surveying by: SCALE DRAWN JOB. N0. UP/2�aA 98 ABUTTING EXISTING S.A.S. THE 699 MAIN SREET, LLC Engineering Works WARNER SURVEYING 1"=20 P.T.M. 82-10 PARKING 4 ROWS OF 6 - 16" HIGH CAP.(H 20) BIODIFFU SERS c/o BRIAN SMITH 12 West Cr—field Road 22 Long Rood „�✓� �FA 1 ROW OF 5 - 16" HIGH CAP.(H20) BIODIFFUSERS 699 MAIN STREET Foreatdale,MA 02644 Horwioh,MA 02645 DATE CHECKED SHEET NO. OSTERVILLE, MA 02655 1 (508) 477-5313 (508) 432-8309 7/27/10 P.T.M. 1 of 2 r- DESIGN CRITERIA EXTEND a 10 BUILDING USAGE (310 CMR 15.203), ABOVE VENT-2 1ST FLOOR - SUPERMARKET - 3300 SF x 97 GPD/1000 SF = 320.1 GPD 2ND FLOOR - OFFICE - 1180 SF x 75 GPD/1000 SF = 88.5 GPD AIR PUMP IN ADD VENT-2 3RD FLOOR - OFFICE - 865 SF x 75 GPD/1000 SF = 64.9 GPD SET 2' ABOVE. GRADE' WATERTIGHT BASIN TOTAL FLOW = 473.5 GPD 110 VAC ACTUAL WATER USAGE: EXISTING EXISTING EACH VENT SHALL BE 2005 - 145,000 GALLONS - AVERAGE DAILY FLOW = 397 GPO EXISTING EXISTING CONNECTED TO ALL 2006 - UNRELIABLE DUE TO LEAK IN WATER SERVICE (REPAIRED) DISTRIBUTION LINES 2007 - 169,D00 GALLONS - AVERAGE DAILY FLOW = 463 GPD g^ GEOGRID EX TEND1 FT.�BE YOND S.A.S. DAILY FLOW: 463 GPD TO E,.! 2"SCH 40 PVC DESIGN FLOW: 474 GPD ^! s 11IN3VERT -- DESIGN FLOW PROVIDED: 0.74 x 562.8 = 638.5 GPD INSTALL J EXISTING EXISTING4 ROWS OF L'FFLUENT EXISTING AND 11 ROW UNITS AT AT =33107' FlLOR EXISTING D-BOX / (ZAeEL OR Eouu>. EXISTING EXISTING EXISTING 5 OUTLETS (MIN.) EXISITNG SOIL ABSORPTION SYSTEM (PROFILE) SludgeHammer• Model S-86 to be EXISTING PUMP CHAMBER installed as shown on Schematic for CHANGE OUT PUMP RESTORED PAVED PARKING&BRICK WALKS 12 OF COMPACTED GRAVEL General Use Approval • Manufacturer: SludgeHammer Group Ltd. ORENCD HIGH-HEAD EFFLUENT PUMP BACKFILL WITH CLEAN NAIVE SAND 336 South Division Rd. EASY PACK AS PROVIDED BY P¢fOeky, MI 49770 ALL CAPE ENVRONMENTAL aRF7fco CON TROL PANEL _ BIAXIAL GEOGRID /BX1100 MODEL NO.MVP-St PT RO _ TYPE PRODUCED BY TENSAR EXISTING SEPTIC TANK ANCHOR S01FNnBc FIOATs CORP., A7LANTA, GA DOSING & STORAGE REQUIREMENTS (ADD ZABEL FILTER, MODEL NO. A1O0) MODEL NO.SM15N0 6^ EXISTING GREASE TRAP II n I�IIIII�II DESIGN FLOW: 474 GPD ADO ZABEL FILTER, MODEL NO. A600 2.8' DOSING: PUMP SHALL SET TO RUN AT ONE HOUR INTERVALS OVER ( ) OVER THE COURSE OF THE DAY. EFFECTIVE WIDTH=1 C. PROPOSED FLOATS SHALL BE: EXISTING SUITABLE 1) PUMP OFF MATERIAL 2) TIMER ON/OFF (4 ROWS OF 6) + (1 ROW OF 5) = 5 ROWS (29 UNITS) 3) TIMER OVERRIDE WITH NO SEPARATION BETWEEN EACH ROW & NO STONE 4) HIGH LEVEL ALARM (SET AT 24") EXISITNIG SOIL ABSORPTION SYSTEM (SECTION) STORAGE PROVIDED: 2.25' BETWEEN INV.(IN) AND HIGH LEVEL ALARM STORAGE PROVIDED = 2.25' X 250 GAL/FT = 562.5 GALLONS SEPTIC SYSTEM PROFILE N.T.S. PROPOSED SLUDGEHAMMER INSTALLATION 699 MAIN STREET, OSTERVILLE, MA Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 Engineering by: Surveying by: SCALE DRAWN JOB. NO. EngineeringWorkc WARNER SURVEYING NTS P.T.M. 182-10 12 West Crossfield Road 22 Long Road Farestdale,MA 02644 Harwich,MA 02645 DA7E - CHECKED SHEET NO. (508)477-5313 (508) 432-8309 7/27/10 P.T.M. 2 Of 3 Cape Fish&Lobster Co., Inc. INVOICE 106809 Page 1 of 1 P.O. Box 753 Centerville, MA 02632 DATE 07/28/16 Payment Due=_> 08/27/16 Phone:(508)771-1122 Fax: (508)790-1439 Printed 07/28/16 09:22:32 AM Commitment to Qua-&q CUSTOMER Copy Sold To: Ship To: FANCY'S FARM MARKET FANCY'S FARM MARKET 699 MAIN STREET 699 MAIN STREET OSTERVILLE, MA 02655 OSTERVILLE, MA 02655 508-420-0863 508-420-0863 Customer I Customer PO Number Order No hl Date hi ed Vla Frei ht RouteSto Sales Broker FANC10 015552 07/28/15 Charge 00 01 QuantityOrdered Product Descri tlon Quantity Shipped Price Amount 14.35LB SAL32025 ATL SALMON FILLETS (C) F/R 14.35 LB $8.95 LB $128.43 10.4 .LB COD30036 ICE COD FILLETS 12oz + 10.4 LB $8.95 LB $93.08 10 LB SCA51015 FRESH $EA SCALLOPS LG DB 10 LB $15.95 LB $159.50 10 LB SHR62151 16-20 IQF PDT-ON TIGER SH CENS 10 LB $9.95 LB $99.50 Lot 00-071316 I weight 44.75 LB Terms Net 30 Days. PAY THIS >> $480.51 (Truck pre-chilled to 45 F or below. shellstock at 50 F or below or iced. shipping time: CLAIMS MUST BE MADE WITHIN 24 HRS, A FINANCE CHARGE OF 1-12% PER MONTH (18% PER ANNUM) WILL BE CHARGED TO ALL OVERDUE ACCOUNTS. ANY ATTORNEY FEES INCURRED TO COLLECT PAYMENT WILL BE PAID BY CUSTOMER. Reinhart Aodservice, L.L.C. PO#.:rEit 6/30 225 JgHN "XCOCK ROAD TADM)jN, MA" 02780-7318 (508)821-2060; (900)669-60y 0' ei0 a t -4411M Fed ID: 36-4 121934 De1v Date: 06/30/16 Get it right from us. Boston Division ****** I N V O I C E ****** DATE INVOICE SLM ACCT NO S FANCY S MARKET S 06/30/16 539314 181 17,554 ' H 699 MAIN STREET 0 PHONE NO TRIP STOP PAGE I L 508-428-6954 434 020 2 P OSTERVILLE MA 02655 D TERMS: 7 Day T T 0 0 SLM: 181 BETH TAYLOR GUANTITY PORTION UNIT SIZE BRAND ITEM DESCRIPTION A ORDER SHIP NUMBER # OF RC X UNIT PRICE EXTENSION RU UN UN A 4 CS 6/5 UP PACKER AE076 TENDERLOIN BF Sup SEL REF i6 1 Oz .721 WEIGHING 145.00 LBS @ 11A4 1,673.30 CWTs: 35.40 36.10 47.30 36.20 f 1 CS 3/11 UP CAB AL690 BEEF FLANK STK.REF 16 .:1 Oz .337 WEIGHING J37-:-90,LBS'@ 5.39 204.28 • 2 CS 6/13 LB CAB AL772. STRTPLOINI ANG Oxl REF 16 1 OZ .593 WEIGHING 118.80 LBS @ 9.49 1,127.41 CWTs: 60.40 58.40 �. 1 CS 4/20 UP CAB AL660 BEEF RIB CH ANG EXPORT 16 1 Oz .488 WEIGHING 57.10.LBS @ 7.80 445.38 10 CS 4/10 LB AIR BB316 CHICK BRST BNLS FIL RNDM 16 1 Oz .106 WEIGHING '400.00 LBS @ 1.69 676.00 1 CS 4/10 LB" AIR BB694 CHICK TENDER BNLS JBO 16 1 Oz .140 WEIGHING 40.00 LBS @ 2.24 89.60 • 3 CS 8/2 LB PACKER AE650 PORK TENDERLOIN FRESH" 16 1 0z .193 WEIGHING 41.00 LBS @ 3.09 126.69 CWTs: 12.70 13.20 15.10 ® 1 CS 6/9 LB PACKER AC122 PORK LOIN BNLS REF 16 1 0z .091 WEIGHING 47.50 LBS @ 1.45 68.68 p 1 CS 20/UP PACKER AK586 LAMB RACK 22-26oz AUSSIE 16 1 Oz .687 - WEIGHING 16.98 LBS (v 10.99 186.61 5 CS 4/3.7 U SUPRFL AK576 LAMB LOIN TRIM SPLIT 4x4 16 1 0z .341 WEIGHING 74.95 LBS 0 5.45 408.48 CWTs: 18.33 17.83 10.33 14.13 14.33 e 1 CS 10/3 La GRTO,MA AEO;6:0 :BEEF CHCK FLAKE#rySHRT RIB., w y3i' %'�•WFi'IGFNG Y;:y:> 1'1 .. I� �{f..': 5.55 173.72 EN {'E CRSldd 'lv: i is :`•c' :><i' • 3 CS 12/1 'ANkAB 22Z•'(I0 Av6ffiO PULP?# T";: « A$S7+ >12. .,., ,[1Z :.123B: 53.38 160.14 * * * MISCELLANEOUS 1 EA 1/CNT, CATG78 F4794 FUEL SURCHARGE 1 1 EA 6.000 6.00 6.00.-'% r 'Toe arfenaDt e r ul ore] ceamatlt Uee 1fete on tn1 TAX DRY FRZ COOL FRZ2 R/S WHS6 TOTAL WEIGHT CUBE 1n M era e tl u ec a the et to or tru�auto r ea se n c o9 r neD a rj u t�rep Cameo 1 fee ,J (?9u"s t I. �neRpelS at Enaso c n r.E..$a -. late over Qne a Memo ttte e4��ny (or tee of foe or of7iar Drmtlutce Serf etl them.hleee 10 7 7 3 9 0 2 3 OB 87 �ne°e°eecoteiobfliie°uKti1`Iu�4DDeyem°ent is°C�ecetvegm,tne ee a of 10,987.42 PAY THIS AMOUNT Reinhart Foodservice, L.L-.C.225 J6M PO#:mt 6/3 0• r i-HAWCOCK ROAD TAUNTON, MA 02y.80-7318(50 )821- (800)669 0Y4600 Rpiin, h a son _ t Fed ID: 3 6-4121934 Dely Date: 06/30/16 Get it right from:us. Boston Division o�-. *,►•rt** I N v O I C IF ♦***** DATE INVOICE SLM ACCT�NO 06/30/16 539314 181 17554� S FANCY'S MARKET S H 699 MAIN STREET 0 PHONE N0 TRIP STOP IPAGE . P D 508-428-6954 434 020 1 T OSTERVILLE MA•02655 T TERMS: 7 Day 0 0 SLM: 181 BETH TAYLOR QUANTITY PORTION ITEM T ORDER 'SHIP UNIT SIZE BRAND NUMBER DESCRIPTION # OF RC X UNIT PRICE EXTENSION RU UN UN w w w FROZEN s It 2 CS 5/2 LB SEAMAZ AG206 SHRIMP WHIE CKD P&D 21-25 160 1 oz .049 e WEIGHIN3 20.00 LBS @ 7.86 157.20 2 CS 36/5 OZ MATLAW 75162 CLAM GRMT .LARGE STFD FZ 36 1 EA 1.089 39.20 78.40 6 CS 2/5 LB TYSON AL460 CHICK BRD TENDER BUFFALO 16o 1 oz .025 WEIGHING3 60.00 LBS @ , 4.00 240.00 * * REFRIGERATED + k * , � i5 2 CS 10/LBS KAYEM AF444: FRANK,ALL MEAT 6f=1 N/C 4 60 1 EA 069 WEIGHING 20.00 LBS @ 4.15 0"51% 83.00 002 CS_ 24/16 0 0SCARM AF684 BACON.REGULAR REF 384 1 Oz .344 132.26 ,r 5 CS 12/12 0 KAYEM AF306 FRANK BEEF N/C OLD TYME 144 1 0z .318 45.81 229.05 'Q2 CS 12/16 O 0SCARM AF688 BACON THICK REF 192 1 02 .340 65.23 130.46 w^ CS 16/14 02MATHAN BL150 FRANK BF 5" 8-1 SKNLS. 210 1 oz .380 79.81 319.24 4 CS 12/12 0 HEBNTL AC326 FRANK BF REF 144 1 oz .402 57.85 231.40 3 CS 8/12 OZ ALFRES AF414 SAUSAGE CHICK ANDL LNK 96 1 0z .338 32.42 97.26 3 CS 8/12 OZ ALFRES E2472 SAUSAGE C-TICK LNK GAR 96 1 Oz .314 30.14 90.42 3 CS 8/12 OZ ALFRES E4226 SAUSAGE CHICK LNK ITAL 96 1 Oz .314 30:14 90.42 3.CS 8/12 OZ ALFRES E4230 SAUSAGE CHICK LNK'SWT "APP 96 1 oz .314 30.14 90.42 • 1 CS 8/12 OZ ALFRES V0626 MEATBALL CHICK TOM/BASIL 96 1 OZ .313 30.07 30.07 2 CS 2/13 LB PACKER AC452 RIBEYE 131b BNLS PRIME i6 1 OZ .687 WEIGHING 55.40 LBS g 10.99 608.85 CWTs: 28.00 27.40 • 4 CS 4/16 U$s BPw,?::<_g. 3 8i:;6:.S;lRLOIDF;:>.:PLAP,.iaFF i!3J:•BNLS:::CH #:6: ?1�02 5:99 1,650.63 i« W #»f4.6t0' %•` .60 . b7.R0 C mow:: 4 CS 3 20 L& "'s :_> r e / f' '#2 B TSID6%NG X i R r' 46 Y;so2 .rY15o 4HING ' '.z.::,.�:s;, }" ,,; 2.ao 630.88 CC�iTS`: 55``00 ' 68 64 *+1D '; 74.30 LG r 4 CS 3/22 UP PACKER G9950 CHUCK SHOULDER CLOD 22up 16 1 oz .141 WEIGHING ' 241.70 LBS @ 2.25 543.03 CWTs: r 65.40 • 60.00 • 57.80 58.50 01 CS 5/2 LB PACKER AL960 VEAL STEW MEAT REF 16 i Oz .312 WEIGHING 11.80 LBS @ 4.9.9 58.88 'Tha vrlaheblf°grl ultur°1 co A!va l atvp on tnl TAX DRY FRZ COOL FRZ2 R/S WHS6 TOTAL WEIGHT CUBE n(te�g Eu `b tPne°e RBe SuYt181.1 f*8lut0s°1I(°0 c4@1Op1 I•eeT°redine'a Egdruat la:mpov r([nvyaa C1�®o a1•st °Ommalti�e No.of nnf o'C°f°Glee OrOo�o-olsHroa p�i i0ii°ot �neaa com°ablolaa uXtlq quTF o°rment to racalvae.' CONTINUED PAY THIS AMOUNT CONTINUED TO PAGE 2 I r—y �AB = Town of Barnstable R.egulatory Services Barnstable Richard Scali Director "*Amedcara" Public Health Division .� I Thomas McKean,Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 3,2017 TO: Jeffrey Lindsey,Fancy's Market FROM: Thomas McKean,Direc RE: Proposed Use of Rear Building ------------------------------------------------------------------------------------------------------------------------------------------ I am in receipt of your letter today regarding the proposed use of a rear building to be used for food preparation at 705 Main Street. The sketch plan which you submitted appears to be incomplete;there is no handwash sink nor a mop sink location provided. We will need manufacturer information or cut sheets for the proposed equipment(i.e.refrigerator, freezer,stove,sinks). Also, a finish schedule(i.e.type of finish construction for the floors,walls,and ceilings)will need to be discussed and determined. In addition, an inground grease trap with a minimum capacity of 1,000 gallons is required per the Town of " Barnstable Code. However during the past twenty to twenty-five years,the Board has granted variances to many businesses in this regard(for example: at properties where there is insufficient space for a 1,000 gallon grease trap). Also,grease recovery devices such as Trapzilla,have been approved if the proposed menu is restricted to foods with little to no grease. If you wish to install a"Trapzilla"or other mechanical recovery device in lieu of a minimum 1,000 gallon capacity grease trap as you noted in your letter,you must first submit a variance request form and a proposed menu to the Board of Health. The variance application fee is$95.00. Attached I provided information for you to review including: general information from the Town's website, a checklist form for you to complete, an application form, finish schedule information, .and other information. You can access this information at our website :www.town.bamstable.ma.us at the Health.Division page. d to submit the information lease set-up an appointment with Health Inspector Donald When you are ready ,P P Wh Y Y Desmarais R.S.to review your application,equipment checklist,proposed floor plan,cut sheets,and finish schedule information. He can be reached at(508)862-4644 or(508)862-4740. ar, ' I To:Thomas McKean, Director of Barnstable Health Division From:Jeffrey Lindsey,owner of Fancy's Market in Osterville 3> Re: Use of building 705 Main St,adjacent to Fancy's,for food prep ry We seek permission to use the kitchen in the 705 building on my property,during summer months,for N the preparation of food for our catering business.The building is a small house historically used to house summer employees and sits about 40 feet from our walk in refrigerated trailer and 60 feet from the back entrance to the store.The 705 building shares a septic system with the 707 Main St apartment building which is occupied in the summer only for about 10 weeks. Our small kitchen in Fancy's Market at 699 Main St becomes quite cramped and busy supplying prepared foods for sale in the store in the summer, when our business approximately triples from winter months.We would add a commercial stove and hood,a chest freezer,a 3 bay sink,a greasetrap under the sink,a trapzilla grease trap next to the septic. system,and 2 stainless steel prep tables only. We would use the space to prepare foods,simply hot and cold platters,for our catering business. Please see attached documents. I seek your input on any requirements we must meet,which will be important to my cost analysis and determination on whether or not this idea would be cost prohibitive.Thank you for your time and consideration. Jeff Lindsey Fancy's Market,699 Main St,Osterville 508-681-0146 i Town of Barnstable Geographic Information System February 22,2016 N. N. wv V2 .................. . . . . . . . ' I tis e NIS h- Y 4 4 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:141 Parcel:012 boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel w+ 1^=100'may not meet established map accuracy standards. The parcel lines on this map Owner:1406 MAIN STREET LLC Total Assessed Value:$686800 are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.53 acres Abutters F. boundaries and do not represent accurate relationships to physical features on the map Location:705 MAIN STREET(OST.) such as building locations. Buffer �f`. Town of Barnstable Geographic Information System February 22,2016 I M� D 8 f 40 Feet DISCLAIMERS:This ma Is for planning Ma 141 Parcel:012 Selected Parcel p p In8 purposes only. It Is not adequate for legal P� boundary.determination or regulatory Interpretation. Enlargements beyond a scale of Owner:1406 MAIN STREET LLC Total Assessed Value:$686800 1'=100'may not meet established map accuracy standards. The parcel lines on this map are only graphic representations of Assessor's tax parcels.They are not true property Co-Owner: Acreage:0.53 acres Abutters E boundaries and do not represent accurate relationships to physical features on the map Location:705 MAIN STREET(OST.) such as building locations. Buffer :+', a i d � k d � O � s LD 1 .� � Ct M 'J � 1_.1 C- ra L V f`f I '4r C3 0 � r My Account(/customer/account) (0)Items(9) (http://thermaco.com/trapzilla) ao � A THIMMACO®Technology FREE SHIPPING - Call: 800-633-4204 (tel://800-633-4204) ON ORDERS OVER $L20 � Online c)mers for Canfiqwous lIS Qnly WO a J Search catalog.._ Store About Trapzilla FOG Resources (/big-dipper/products/)(http://thermaco.com/about-trapzilla)(http://thermaco.com/resources) Specifications Find a Rep Contact Us Replacement Parts (/a bout/p rod uct-specs-d rawi ngs)(/fi nd-a-rep) (/contact-us) (/parts-store.html) Home(http://thermaco.com/) About Trapzilla(http://thermaco.com/about-trapzilia/) Advantages ADVANTAGES Trapzilla Supercapacity Grease Interceptor Advantages Trapzilla grease traps have a number of advantages over traditional concrete traps. High Retention Capacity Though compact in size,Trapzilla traps have a very high capacity.They can store more than 85 percent of their volume in grease,much higher than the 25 percent that concrete traps can handle.For example,the TZ-600 can hold 635 pounds(288 Kg)of fats,oil and cam t t; grease. That exceeds the ASME required capacity by 323%! Why not choose the grease o • interceptor that offers more protection from passing on grease to the sewer collection a m system? • • Highly Efficient Unlike traditional concrete traps,Trapzilla traps maintain the same high level of efficiency(above 90 percent)even as it fills up with grease.This means there is no danger of commercial kitchen accidentally falling out of compliance just because its grease trap is starting to get full. From day one until the day it is full,it continues to operate efficiehtly separating and retaining grease,protecting your facility from fines and costly f e Durable Construction Trapzilla grease interceptors are constructed of durable polyethylene.This means it is more resistant to acids and biological contents than traditional concrete interceptors and steel grease traps and will last longer in real world conditions. Flexible Installation Options Trapzilla interceptors can be installed in a variety of configurations,including: > Buried in the ground > Embedded in the floor of the kitchen > Sitting on the floor in basement or mechanical room > Between floors and ceiling in interstitial space In addition,for commercial kitchens producing very high volumes of grease, ' i multiple Trapzailla units can be plumbed in parallel to provide even more grease trap capacity. Low Total Cost of Ownership When you consider the separation and retention efficiency found in Trapzilla's durable,compact design,it is easy to see why Trapzilla has such a low Total Cost of Ownership. While other interceptors fail over time,and still others fail to protect you from blockages,fines,and costly downtime, Trapzilla will keep working to keep you in compliance so you can focus on what you really love. Click here to see current Trapzilla Models available(/trapzilla/products) About Trapzilla (hhttp:/thhermaco.com/about-trapzilla) . i Trapzilla Products(http:lithermaco.com/about-trapzilia/where) f � t Operation(http:/thhemmaco.com/about-trapzilla/operation) Advantages(gyp://thermaco.com/about-trapzilla/advantages) w i Specifications &Drawings(httpJthhermaco.com/about-trapzilia/specifications) s Installation(http://Ihermaco.com/about-trapzillafinstallafion) Service(http://thermaco.com/about-trapzilia/Service) TZ-1826 Grease Interceptor(httpJ/Ihermaco.com/about-trapzilialbigtz) Videos(httpJtthermaco.com/about-trapzilla/videos) # i Patent Info(/about/patents) Approvals&Certifications(/about/approvals) 4 \ T#vn of Barnstable • Barnstable Board of Health AHnvdcaCffj MASS. 200 Main Street, Hyannis MA 02601 •639. �� 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Junichi Sawayanagi Paul Canniff,D.M.D. o September 20, 2010 Mr. Winstead'A. Steadman II All Cape Environmental.Inc, PO Box 235 Yarmouth-Port, MA. 02675-0235 :Mam Street,=0sterville =-iF :s A= 141 - ill Dear Mr. Steadman: You are granted permission to use the Innovative/Alternative Sludgehammer S-86 System to improve the functionality of the septic system at 699 Main Street, Osterville with the following conditions.: 1) The applicant must meet all of the general use approval-conditions issued by the Massachusetts Department of Environmental Protection (DEP) pursuant to Title V, 310 CMR 15.000. 2) The applicant must monitor the system once per month during the first six months of operation, then quarterly thereafter for the following eighteen months for the following parameters: BOD's,-pH and TSS. This general use approval is granted because the soil absorption system was recently replaced due to structural failure. Sincere) yours, r W yne iller, D. Chain n - f Q:\WPFILES\699 Main St Ost Fancysjan2011.doc p �OI/023cL 10/12/2010 Town of Barnstable o Board of Health (� 200 Main Street, Hyannis, MA. 02601 I+'anc=v ti Market 6,99 Main Street, Osi.ervil.le M_ a Dear Board of Health Members I During installation of additional vents and inspection ports, the SAS was discovered to have structurally faeld. No determination was made as to cause of failure.A permit was obtained to replace the SAS.All old material was removed and new material brought in. } e The system was installed with two vents, one at each end of the field.. Inspection ports were installed at the end of each row.A filtered pump system was installed and the ° discharge of the pump is done by a timer. The dosing cycle is hourly with a run time of e three minutes. The pump discharge was throttled back to only allow 10 gpm +/-. The i{ measured three minute dose yeilded 33 gallons. i Under the current circumstances the Sludgehammer ABG cannot be installed under the Remedial Approval. b Y I would like to request that a General Approval of the Sludgehammer be granted. � Enclosed you will find the state general approval letter and a monitoring plan for the next f two years. I$� I If I can be of further assistance please feel free to contact me at 774-313-6602 cell or at my f I office 508-776-6219 or by email wsteadmanii@comcast.net I .-=• ;.. Sinc rely to d� q '-_ -n N � Winston A. Steadman II T' All Cape Environmental Inc. 3 O r C rn S� i4 SLUDGEHAMMER ABG S-86 2 Year Monitoring Plan for Fancy's Market October 2010 thru October 2012 For the first month after instaillation: Weekly Inspections/Monitoring(minimum of 4 weeks) 1. Monitoring of SAS liquid levels by means of visual inspection. 2. Field sampling of effluent at inlet of pump chamber testing for PH, DO,Turbidity and Temperature 3. Field sampling of effluent at D-Box for PH, DO,Turbidity and Temperature 4. Inspection of Septic Tank for sludge and scum levels 5. Inspection of Grease Trap for depth of grease 6. Inspection of all filters 7. Inspection of ABG unit and compressor 8. Inspection of Pump Chamber sludge and scum levels 9. Water use readings 10. Pump run times and override events(making adjustments as required) At the end of 4 weeks a lab sample will be pulled testing for BODs and TSS along with field sampling for PH, DO, Turbidity, and Temperature. At the end of one month and successful operation of upgrade the above monitoring plan will move to a quarterly schedule with lab samples for Bods and TSS sampled at the D-Box. Quarterly schedule to remain in effect for the next two years, at which time owner may request reduction in monitoring/sampling from the Board of Health. If during a quarterly inspection, system fails any of the field tests,weekly monitoring will be placed in effect and reason for failure corrected. Weekly monitoring to continue for a minimum of two weeks after passing field tests. Passing field tests are 1. DO-greater than 2 rrg/I 2. PH—between 6&9 SU 3. Turbidity—less than 40 NTU 4. No offensive odor All Inspections/maintenance to be entered into Barnstable County Health Department Carmody data base Rev 2 10/12/2010 General I� i �\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENERGY & ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 s DEVAL L.PATRICK IAN A.BOWLES Governor Secretary TIMOTHY P.MURRAY LAURIE BURT Lieutenant Governor Commissioner APPROVAL FOR GENERAL USE Pursuant to Title 5, 310 CMR 15.000 Name and Address of Applicant: SludgeHammer Group Ltd. 336 S. Division Road Petoskey, MI 49770 Trade name and model of technology: SludgeHammer ABG, models S-46 and S-86 (hereinafter the "System"). Schematic drawings of a typical System and technology checklist are attached as part of this Approval. Transmittal Number: X228156 Date of Issuance: August 27, 2009 Expiration Date: August 27, 2014 Authority for Issuance Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000, the Department of Environmental Protection hereby issues this Approval for General Use to: SludgeHammer Group Ltd. 336 S. Division Road, Petoskey, MI 49770 (hereinafter "the Company"), approving the System described herein for General Use in the Commonwealth of Massachusetts. Sale and use of the System are conditioned on and subject to compliance by the Company and the System owner with the terms and conditions set forth below. Any noncompliance with the terms or conditions of this Certification constitutes a violation of 310 CMR 15.000. C August 27, 2009 Glenn Haas, Acting Assistant Commissioner Date Bureau of Resource Protection Department of Environmental Protection This information is available in alternate format.Call Donald M.Comes,ADA Coordinator at 617-556-1057.TDD#1-866-539-7622 or 1-617-574-6868. MassDEP on the World Wide Web: http://www.mass.gov/dep (10 Printed on Recycled Paper Sludgehammer Approval for General Use Page 2 of 6 I. Purpose 1. The purpose of this Certification is to allow use of the System in Massachusetts, on a General Use basis to enhance and maintain performance of properly functioning soil absorption System (SAS). 2. With the necessary permits and approvals required by 310 CMR 15.000, this Approval for General Use authorizes the use of the System in Massachusetts. 3. The System is approved for the use at facilities with a maximum design flow less than 2000 gallons per day (GPD). 4. The System may only be installed on all facilities where a system in full compliance with 310 CMR 15.000 exists working SAS or will be built and has been approved by the local approving authority, or by DEP if DEP approval is required. 5. This Approval is limited to the applicant's use of the technology. MassDEP makes no determination concerning any ownership interest or any other property or legal rights associated with.the use of the technology. Il. Design Standards 1. The System consists of an aeration device, 40 watt unit operated on a continuous basis, and a System bacterial source installed in an existing septic tank or a new septic tank designed in accord mmce with 310 CMR 15.223 through 15.228. The bacterial source consists of plastic media coated with the bacteria. The System converts the septic tank into a facultative bioreactor to treat residential strength wastewater from facilities with a design flow of less than 2,000 GPD. The treated effluent is discharged to the SAS. 2. A microbial culture is established in the septic tank and maintained using aeration device and the microbial source. The aerator mixes the contents of the septic tank with the microbes and aerates the liquid. The System's biomass reduces both the biochemical oxygen demand (BODO and the total suspended solids (TSS) concentration in the effluent from the septic tank. 3. For seasonal use, the System shall be reactivated by the addition of a fresh culture of microbes at each start up. 111. General Conditions 1. The provisions of 310 CMR 1.5.000 are applicable to the use of the System, the system owner and the Company, except those that specifically have been varied by the terms of this Approval.. 2. The facility served by the System, and the System itself, shall be open to inspection and sampling by the Department and the local approving authority at all reasonable times. 0 Sludgehammer Approval for General Use Page 3 of 6 3. In accordance with applicable law, the Department and the local approving authority may require the System owner to cease use of the System and/or to take any other action as it deems necessary to protect public health, safety, welfare or the environment. 4. The Department has not determined that the performance of the System will provide a level of protection to the environment that is at least equivalent to that of a sewer. Accordingly, no new System shall be constructed, and no System shall be upgraded or expanded, if it is feasible to connect the facility to a sanitary sewer, unless allowed pursuant to 310 CMR 15.004. IV. Conditions Applicable to the System Owner 1. The System is approved for the treatment and disposal of sanitary sewage only. Any wastes that are non-sanitary sewage generated or used at the facility served by the System shall not be introduced into the on-site sewage disposal system and shall be lawfully disposed of. 2. Operation and Maintenance Agreement A. Throughout its life, the System owner shall operate and maintain the system in accordance with the Company and designer's operation and maintenance requirements and this Approval. To ensure proper operation and maintenance (O&M), the System owner shall enter into an O&M agreement. No O&M agreement shall be less than one year. B. No System shall be used until an O&M agreement is submitted to the approving authority which: i. Provides for the contracting with the Company or its approved operation and maintenance contractor, trained by the Company as provided in Section V(7), to operate the System's specifications and the operation and maintenance requirements specified by the designer and any specified by the Department; ii. Contains procedures for notification to the Department and the local board of health within five days of system failure or alarm event and for corrective measures to be taken immediately; iii. Provides the name of an operator, which must be a Massachusetts certified operator if one is required by 257 CMR 2.00 that will operate and monitor the System. The operator must inspect the System at least every six months and anytime there is an alarm event. 3. The System owner shall at all times have the System properly operated and maintained in accordance with this Approval, the designer's operation and maintenance requirements and the company's approved operating procedures. The System owner shall notify the Department and the local approving V Sludgehammer Approval for General Use Page 4 of 6 authority in writing within seven days of any cancellation, expiration or other change in the terms and/or conditions of their O&M agreement. 4. Prior to transferring any or all interest in the property served by the system, or any portion of the property, including any possessory interest,the System owner shall provide written notice of all conditions contained in this Approval to the transferee(s). Any and all instruments of transfer and any leases or rental agreements shall include as an exhibit attached thereto and made a part of thereof a copy of this Approval for the System. The System owner shall send a copy of such written notification(s)to the local approving authority within 10 days of such notice being given. 5. By February 151h of each year for the previous year, the System owner shall submit to the approving authority all operation, maintenance, and monitoring data collected by the System operator, including an O&M checklist and a technology checklist. This information shall be completed by the System operator for each inspection performed during the previous calendar year. A copy of the technology checklist is attached to this Approval. 6. Prior to the issuance of a Certificate of Compliance for the system,the System owner shall record and/or register in the appropriate Registry of Deeds and/or Land Registration Office, a Notice disclosing the existence of the alternative system subject to this Approval on the property. If the property subject to the Notice is unregistered land, the Notice shall be marginally referenced on the owner's deed to the property. Within 30 days of recording and/or registering the Notice, the System owner shall submit the following to the local approving authority: (i) a certified Registry copy of the Notice bearing the book and page/or document number; and (ii) if the property is unregistered land, a Registry copy of the owner's deed to the property, bearing the marginal reference. V. Conditions Applicable to the Company 1. By February 1 S'h of each year, the Company shall submit to the Department a report, signed by a corporate officer, general partner, or Company owner that contains information on the System for the previous calendar year. The report shall identify all locations where the System was installed in the prior year, state known failures, malfunctions, and corrective actions taken for the System as well as the date and address of each event. 2. The Company shall notify the Department's Director of Wastewater Management Program at least 30 days in advance of any proposed transfer of ownership of the technology for which this Certification is issued. Said notification shall include the name and address of the proposed new owner and a written agreement between the existing and proposed new owner containing a specific date for transfer of ownership, responsibility, coverage and liability between them. All provisions of this Certification applicable to the Company Sludgehammer Approval for General Use Page 5 of 6 shall be applicable to successors and assigns of the Company, unless the Department determines otherwise. 3. The Company shall furnish the Department any information that the Department requests regarding the System, within 21 days of the date of receipt of that request. 4. Prior to any sale of the System, the Company shall provide the purchaser with a copy of this Certification. In any contract for distribution or sale of the System, the Company shall require the distributor or seller to provide the purchaser of the System, prior to any sale of the System, with a copy of this Certification. 5. The Company shall prepare and provide the Department an installation manual specifically detailing procedures for installation of its System. The Company shall institute and maintain a training program in the proper installation of its System in accordance with the manual and provide a training course at least annually for prospective installers. The Company shall certify that installers have passed the Company's training qualifications, maintain a list of certified installers, submit a copy to the Department, and update the list annually. Updated lists shall be forwarded to the Department. 6. The Company shall not sell the System to installers unless they are trained to install these Systems by the Company. 7. The Company shall institute and maintain a program of operator training. The Company shall maintain and annually update, and make the list of qualified operators available by February 1 sc of each year. The company shall make the list known to users of the technology. 8. The Company or the Company's approved operation and maintenance contractor shall maintain a contract with the system owner that: A. Provides for operating and maintaining the System with an operator that has been trained by the Company to operate the System consistent with the System's specifications and any additional operation and maintenance requirements specified by the designer or by the Department; B. Contains procedures for notification to the System owner, the Department and the local approving authority within five days of knowledge of a System failure and for corrective measures to be taken immediately; C. Contains procedures for inspecting the plastic media bacterial source at each bi-annual visit and if necessary replacing the media. At minimum, the microbial inoculants shall be replaced annually. I Sludgehammer • ' Approval for General Use Page 6 of 6 VI. Conditions Applicable to Installers of the System 1. Each Installer shall install the System in accordance with Company training on the installation of the System and the conditions of this Certification. 2. No Installer shall install the System unless the Installer has been trained by the Company on installation of the System. �I VII. Reporting 1. All submittals of notices and documents to the Department required by this Certification shall be submitted to: Director Wastewater Management Program Department of Environmental Protection One Winter Street - 5th floor Boston, Massachusetts 02108 VIII. Rights of the Department 1. The Department may suspend, modify or revoke this Certification for cause, including, but not limited to, non-compliance with the terms of this Certification, non-payment of an annual compliance assurance fee, for obtaining the Certification by misrepresentation or failure to disclose fully all relevant facts or any change in or discovery of conditions that would constitute grounds for discontinuance of the Certification, or as necessary for the protection of public health, safety, welfare or the environment, and as authorized by applicable law. The Department reserves its rights to take any enforcement action authorized by law with respect to this Certification, the System, the owner, or operator of the System and the Company. IX. Expiration Date 1. Notwithstanding the expiration date of this Certification, any System installed prior to the expiration date of this Certification, and approved, installed and maintained in compliance with this Certification (as it may be modified) and 310 CMR 15.000, may remain in use unless the Department, the local approving authority, or a court requires the System to be modified or removed, or requires discharges to the System to cease. � Town of Barnstable aF�i1E Tp� 4• Barnstable Board of Health » AMma9caGity ' BARNSI'ABLE, v MA9S• g 200 Main Street,Hyannis MA 02601 prfD MA'S A 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 7unichi Sawayanagi Paul Canniff,D.M.D. September 20, 2010 Mr. Winstead A. Steadman II All Cape Environmental Inc. PO Box 235 Yarmouth Port, MA 02675-0235 RE: 699 Main Street, Osterville rnNd- s ,�, A = 14.1 - 011 Dear Mr. Steadman: You are granted permission to use the Innovative/Alternative Sludgehammer S-86 System to improve the functionality of the septic system at 699 Main Street, Osterville with the following conditions: Samf_S� -/V 1) The applicant must meet all of the remedia a approval conditions issued by the Massachusetts Departm�t-of vironmental Protection (DEP) pursuant to Title V, 310 CMR 15.000. 2) The system shall be monitored.quarterly during the first two years of operation for the following parameters: BOD's, pH and TSS. e This permission is granted because the existing septic system was in failure at the time of application. Sincer ly yours, W ne iller, M.D. Chairman Q:\WPFILES\699 Main St Ost Fancys Sep2010.doc l , n SludgeHammer ihr The latest advance in P • Home • Applications • Products • News • Case Studies • Dealers • Company • Contact type here to search Search How it works Septic systems fail. And the reason they fail is the soil in the disposal field clogs up with slime from the anaerobic (unoxygenated)bacteria that were once in your digestive system. The very protective coating that allows this bacteria to do its job in your gut ultimately ruins the typical septic system. Until SludgeHammer,you had only two very costly options—you could repair or replace your system. The SludgeHammer is built to give you a third, and better, option. Waste and unoxygenated bacteria are the primary reason for failure of traditional septic systems. When large colonies of these anaerobic bacteria migrate from the septic tank to the disposal field they produce a mucus-like layer of slime, or biomat, which clogs the pores of the soil so air cannot circulate. Additionally, as they grow, this anaerobic bacteria creates large amounts of nitrate, a toxic element when produced in large quantities, which can, over time, seep into the local water table. The usual solution at this point is to pump the waste and clogs from the septic tank and start a new disposal field—costly solutions to a now avoidable situation. Air :prp ttl0UA: Air line inirt Service a e mx riser i P �.. EfflEd':e1'Et i s fliter >r s w.AX Outlet ivv leu F''to Aaro41G Bacteria ifigi3iAtl& System I I The SludgeHammer Answer SludgeHammer provides an integrated two part response to the probl.-m of long-term wastewater management.Oxygen is lethal to the' anaerobic bacteria that inhabit septic systems. Simply and affordably,the SludgeHammer system can be installed into any existing septic system,aerating and circulating the effluent within the septic tank killling off all of the anaerobic bacteria. This introduction of oxygen creates the perfect environment for the SludgeHammer proprietary blend bacteria. The SludgeHammer matrix itself, with 150 square feet of surface area for the bacteria to grow and form colonies on, is placed in the inlet chamber. Liquid in the tank circulates through the unit, over the aerated bacterial colony, at a rate of 15,000-20,000 gallons per day, ensuring that every drop of liquid is processed up to 20 times a day. In this set up, the voracious SludgeHammer blend bacteria consume and digest the organic waste. The SludgeHammer microbes are so efficient that they turn effluent into clear water before it heads to the disposal fields, making clogs nearly impossible, and all this without producing the biomat slime that ruins septic systems. The SludgeHammer bacteria then proceed with the clear effluent into the disposal field where they digest the biomat slime and reopen the soil pores. Even though there is no air mechanically circulated to the disposal field the SludgeHammer microbes still thrive. Instead of directly absorbing oxygen the microbes,strip nitrite of oxygen before it is turned into the more toxic form of nitrate, creating nitrogen gas through the process:Nitrogen, an abundant element within the atmosphere can now circulate out of the soil. As the SludgeHammer microbes digest the biomat the disposal field is revitalized and can once again accept and process the clear effluent coming from the SludgeHammer inoculated septic tank. The SludgeHammer microbes leave no resources for anaerobic bacteria to grow so they are defeated through competitive exclusion. The SludgeHammer microbes do not pose a threat to septic tank and disposal field clogs, because they break down organic matter and do not create the biomat slime produced by anaerobic intestinal bacteria. The bacteria will maintain a colony indefinitely as long as they are provided oxygen and waste, meaning a permanent solution to wastewater clogging and disposal problems. i SludgeHammer Adaptability The SludgeHammer system is a living system.It grows as it has resources and decreases when resources are limited,meaning that it can customize itself to meet any needs. SludgeHammer has proven its adaptability and efficiency at unclogging and revitalizing failed septic systems.The same SludgeHammer system has also been adapted for marine and other uses,where the same basic technology breaks down organic matter into clear water which can then either be reintroduced into the local water table or repurposed for irrigation. Certifications . 1- i Testimonials The Sludgel-larnmer technology was installed in.May of 2003, and it is still. going.strong!There is no.gooey crust. I doubt we will ever.need to pump the tanks again.The sediment is gone. L Y / 1 1 Inc, InnovanunslnPreeasCOraulage Zabel` ZABEL ! I V/a7 ilte �S F IUastevate7Pladucts i� ADNsion cf Pal•ok lnc. s M y. .,uyYWxn'a: R .n'E'.__ E, �n a : OutdoorSmart Filter Alarm J. All Polylok/Zabel filters accept the SmartFilter® Y� l� switch and alarm. ; .� �Y, I A100 Filter 1/16" Filtration A300 Filter 1/32" Filtration A600 Filter 1/64" Filtration 8" and 12" Diameter 8"and 12" Diameter 8"and 12" Diameter This filter is ideal for larger The finer 1/32" level of fil- The A600 is ideal for spe- homes,multi-family homes tration achieved with the cialty applications where or lightcommercial settings A300-8 filter makes this the very fine filtration is where increased flows or perfect effluent filter for required and low flows higher quality effluent small grease trap applica- are expected. Due to fine, is required. The A100-8 tions, dog kennels, laun- 1/64" level filtration, every Series is sized to handle dromats and other appli- A600 comes equipped with flow rates from 1200 to cations where fine sus- a SmartFilter® switch and 2400 GPD and is available in pended solids are present. alarm. The SmartFilter® three different lengths. The The A300 offers flow rates switch provides notification A100-12 Series, installed in between 1200-2400GPD. of required filter servicing more locations than any The A300-12 Series pro- through the use of both an other filter on the market, vides 1/32" filtration and audible and visual alarm. is sized to handle flow has been shown to reduce A minimum of a 3" drop rates from 3000 to 6000 FOG by as much as 50- is required in the tank for GPD. The A100-12 Series 98%. The A300-12 is also proper SmartFilter® opera- can be used in almost any used for onsite wastewater tion. The A600-8 Series application. Independent systems which require a filter is available in 18", 26" research has shown the finer level of TSS removal. and 32" lengths. The A600- A100-12 decreases TSS by The A300-8 Series filter is 12 Series is available in 50-90% and CBODS by 20- available in 12", 26" and 20", 28" and 36" lengths. 40%. With 1/16" filtration, 32" lengths. The A300-12 the A100-8 Series filter is Series filter is available in available in 18", 26" and 20", 28" and 36" lengths. 32" lengths. The A100-12 Series filter is available in 20", 28" and 36" lengths. w.polylolc.com 1-877-765-5565 n ZABEL 12" CASES 0as1 �� 06L3 04so 04sz 04.W 21.75 9.60 ti29 23.50 A16M60012X29 CASE 35.50 AilX4AWO17XZ8 CASE 3125 13.46 o1244 O Q 11.18 e ® A106Afi0012Xi6CA5E �m.ou.u>a4«.a 04� 12'FILTER CASE SERIES MATERIAL: 13b5 12X20 CASE: HOUSING POLYPROPYLENE BUSHING PVC 12X28 AND 12X36 CASES-ABS COLOR-GREY ZABEL 12 FILTER SERIES A-t0017 P1ATE5)15.67' A10026 PLATES 23.89' A100(34 PLATES)31.19' 1 ( 1 A700135 PLATES)3198' A300 IIB PLATES)165 G3' A300(27 PLATES)2423' A600(36 PLATES)71.46' B A300(IS PLATES)15.75- A600(27 PLATES)23A2' e e B B ®' e 8 g B A100-A60D 12X20 CARTRIDGE o p IT FILTER CARTRIDGE SERIES MATERIAL-ABS A100-A60012X28 CARTRIDGE COLOR: A-100-WHITE SOCKETACCEPTS A300-GREEN FILTER SWITCH A300-BLACK a PARF NO.3014B A-100-1118'FILT RATION 1240-13&50 FT. 01195 u A100-A60012X36 CARTRIDGE 12X28.211.90 FT. 12X38.277.10 FT. O A-300.17J2'FILTRATION: 12X20-146.70 IT. 10.fi4 12X28-210.05 FT. 12X36.285.25 FT. A 600.VW FILTRATION: FILTER PLATE 12)(20.141L70 FT. 8.15 FT.OF FILTRATION 12)(28-220.05 FT. _ PER FILTER PLATE 12X36.293.40 FT. www.polylok.com 1-877-765-9565 4 BiotubeoPump Package Applications standard Features.&Benefits. ,,,, Orenco's Biotube®EasyPak' Pump Package is the first pump package • A complete system • Demand dosing and designed specifically for use in pump tanks to filter and pump effluent to in one box timed dosing sys- dispersal.*It includes the following components: • Drops right into a tems available • EasyPak`'pump vault pump tank • Easy to select, • 4-inch turbine effluent pump • All parts designed install,and maintain • Biotube°filter cartridges (3) to work together • To order your free • Flow inducer • Vault keeps out EasyPak Design • Float switches with slidingcollarssludge,but allows Aid CD-ROM,call pumping to nearly 0renco at 800-348- • Discharge plumbing assembly the bottom of the 9843. Or you can • Splice box tank to meet large download every- • Control panel (demand dosing or timed dosing) reserve capacity thing on the CD by visiting the home requirements The kit saves time for the installer and protects the drainfield from clog- page of orenco.com ging. Choose a system for demand dosing (to a gravity drainfield) or Turbine pump lasts and clicking timed dosing(to a pressurized drainfield or mound). four times longer aNew Products' * on than centrifugal or the EasyPak Patent pending pumps and is war- rantied for five graphic. years • Turbine pump with- stands the frequent `', starts and stops that timed dosing requires Patented Biotube° filter has 14 ft2 of filter area 17 3 e � Snap-in float stem and adjustable float y k y -� collars keep floats securely in position,14. t speeding installa- tion and servicing E 7, • Built of molded The EasyPak Pump s >' uu ,` • ,, i r z ABS and PVC for Package replaces long life pump-on-a-block" 71 °' � systems with a complete package thats easy to 9 ::. WMMMMIMITPIK, install and maintain. Combining components for filtration,pumping,and contro4 the EasyPak'T"Pump r�� Package installs quickly in any pump tank purchased separately)and allows pump- ing to nearly the bottom of the tank. • Orenco Systems® Incorporated Changing the Way the World Does Wastewater® APS-PTV-1 Rev.1.2,©05/09 1-800-348-9843 Orenco Systems®,Inc. www.orenco.com Elm i Biotube° EasyPar Components - � ... Float tree Float tree bracket i s - , t Flow inducer r Discharge plumbing I s assembly Control panel Biotube°filter # i (Cold-weather and •Demand dosing systems: cartridges(3) (f drainback discharge Simplex electro- tI assemblies also mechanical panel ! available) 1,6 •Timed-dosing systems: Choice of analog or ,. r digital timer panel ' tI 4-in.turbine r E� t effluent pump 714 � 1. (10,30,or t j f 50 gpm) Splice box' , rA ' I> 1. t ,;.. g 3P EasyPak'vault Float switches with collars • Demand-dosing 'systems: high-level and on/off • Timed-dosing systems: high-level,timer off, 'External splice box also available and redundant off I I Model Code for Ordering To Order BEP u u u Call your nearest Orenco Systems®,jInc. distributor. For nearest distributor, call Orenco Iat (800) 348-9843, or I Discharge assembly: go to orenco.com and click on "Dis'tributor Locator." Blank =Standard DB =Drainback CW =Cold weather Distributed By: Panel: DD = Demand dosing TDA = Timed dosing,analog TDD = Timed dosing,digital Pump flow rate(nominal): 10= 10 gpm(0.6 Usec)with Ya-in.(6-mm)flow control 30=30 gpm(1.9 Usec) 50=50 gpm(3.2 Usec) Biotube EasyPak'"pump vault,l5-inch(380-mm)vault I Town of Barnstable Barnstable SHE Board of Health j `��j MA� I`erg 200 Main Street, Hyannis MA 02601 a 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi May 3, 2015 Michael F. Schulz, Esq. . Shulz Law Offices, LLC 7 Parker Road Osterville, MA RE: Fancy's Market, 699 Main Street, Osterville Extension of Time to Repair Septic System and To Construct Bathroom Dear Attorney Schulz, You are granted an extension, on behalf of your client Adam J. Hostetter, to repair the septic system and construct a second bathroom at Fancy's Market, 699 Main Street, Osterville, Massachusetts. The septic system must be repaired within sixty (60) days, before June 15, 2015. The second bathroom must be constructed within six months, before October 15, 2015 Your client recently acquired this property; we understand a reasonable amount of time is needed to secure contractors to complete the required work. In the meantime, your client is authorized to apply for and obtain a 2015 food permit for this facility.. Sinc ly yours, 9 ayne iller, M.D. Chairm Board of Health Town of Barnstable Q:\WPFILES\SchulzFancysExtensions2Ol5.doc F t SCHULZ LAW OFFICES, LLC WILLIAM CHARLES PLACE 7 PARKER ROAD OSTERVILLE, MASSACHUSETTS 02655-2004 TELEPHONE(508)428-0950 FACSIMILE(505)420-1508 ALBERT J.SC=Z MICHA$L F.SCHULZ I aS&U1z@66U1z1aw0fr1='0bm mtichulz®schulr]awvffiees com i March 20,2015 Thomas A. McKean, Director Board of Health Town of Barnstable 200 Main Street Hyannis, Massachusetts 02601 RE: 699 Main Street, Osterville,Massachusetts 02655 Dear Mr. McKean: I represent 1406 Main Street LLC with respect to its prospective purchase of 699.Main Street, Osterville,Massachusetts 02655 (the"property")which is scheduled to close on March 27,2015. It has come to our attention that the septic system(which is in failure)must be repaired within. sixty(60)days. In the event my client acquires title to the property,my client agrees to repair the system within sixty(60)days. As always,please do not hesitate to contact me should you have any questions. Very Truly Yours, Very T y Yours, (�2 tG hael F, S ulz Adam J. Hostetter 1406 Main Street, LLC' MFS/lw cc: 1406 Main Street, LLC Rebecca Richardson,Esq. l� . . SCHULZ LAW OFFICES, LLC WILLIAM CHARLES PLACE I 7.PARKER ROAD OSTERVILLE, MASSACHUSETTTS 02655-2034 TELEPHONE(508)426-0950 FACSIMILE(506)420-1506 ALBERT J.SCHULZ MICHAEL F.SCHULZ 9Sd1Wz@6chU1Z11 vffices.com machulzfsehUW*Waffices.C= March 20,2015 Thomas A. McKean,Director Board of Health Town of Barnstable 200 Main Street Hyannis,Massachusetts 02601 RE: 699 Main Street, Osterville,Massachusetts 02655 Dear Mr. McKean: I represent 1406 Main Street LLC with respect to its prospective purchase of 699 Main Street, Osterville,Massachusetts 02655(the"property")which is scheduled to close on March 27,_20.15.. Upon acquiring title to the property,my client specifically agrees to install:a second bathroom at the property within six (6)months. As always,please do not hesitate to contact me should you have any questions. Very Truly Yours, Very yYours, 0hael F. Schulz am . Hostetter 1406 Main Street,LLC. MFS/lw cc: 1406 Main Street, LLC i Rebecca Richardson, Esq. II --- b' o v°FSI'E awn of Bai nsta Barnstable P °� Board of Health AMmericaCitY ISARNS'rAQLE, v MASS. 200 Main Street,Hyannis MA 02601 O°p 1639. jEb MAt A 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Junichi Sawayanagi Paul Canniff,D.M.D. September 23, 2009 Mr. Peter McEntee, P.E. Engineering Works 12 West Crossfield Road Forestdale, MA 02644 RE: 699 Main Street, Osterville A = 141 Dear Mr. McEntee, You are granted permission to use the Innovative/Alternative Soil Air System to incorporate aeration into the septic system at 699 Main Street, Osterville with the' following conditions: 1) The applicant must obtain approval from Massachusetts Department of Environmental Protection (DEP). 2) If DEP disapproves the application, the Board of Health must be notified immediately and the Soil Air System must be discontinued within 24 hours. 3) The engineer or qualified operator must monitor the ponding level two times per week and must appear before the Board after the first month to determine further monitoring. 4) If pumping is needed or any high water alarms activate, this must be reported to the Board of Health within 24 hours. This letter will serve in lieu of a septic permit as permission to install the Soil Air System components. This permission is granted because the existing septic system is in failure. This aeration system is temporary. Sincerely yours, Wayne iller, M.D. Chairm n Q:\WPFILES\699 Main St Ost Fancys Aug2009.doc w EXCERPT FROM BOH MEETING AUGUST 4, 2009: Septic Variance (New): A. Peter McEntee, Engineering Works representing The 699 Main Street, LLC,- Fancy's Market— 699 Main Street, Osterville, Map/Parcel 141-011, 0.17 acre parcel, approval requested for I/A Soil Air System on failed septic. Peter McEntee presented the observations with the failure of the septic installed one year ago. George Heufelder, Barnstable County, worked with Mr. McEntee on the situation. He told the owners to put an interceptor grease trap inside as well and stressed to scrap all food off items before washing. The solution proposed is to use the I/A Soil Air System. Mr. McEntee expects the system can be installed in September and would come to the Ocober 13, 2009, Board of Health meeting if a 30-day period has passed. Upon a motion duly made by Mr. Sawayanagi, seconded by Dr. Miller, the Board voted on an emergency installation of the I/A Soil Air System, pending state approval, with the following conditions: 1) if the DEP denies approval, the Board of Health must be notified immediately and the Soil Air System must be ciscontinued within 24 hours, 3) must monitor the ponding level two times a week and appear before the Board after the first month to then determine the monitoring after that time, and 4) if pumping is needed or any high water alarms go off, this must be reported to the Board of Health within 24 hours - one working day. (Unanimously, voted in favor.) Page 1 of 1 Subj: Re: Update on Septic Date: 6/24/2009 12:22:47 P.M. Eastern Daylight Time From: peter.mcentee@gmail.com To: Fancysmarket@aol.com Brian, I honestly think that the system needs to be treated. Given the impact of the sewage effluent, if you rip out the old system and put a new one in without any pretreatment, I think that you will be in the same situation again soon. SoilAir is close to being approved. If you can wait, I would recommend going with them since they have determined that the sample taken from the bottom of the leaching area improved with treatment. I've recently spoken to Dave Potts and he is willing to try to make this work out. Pete On Tue, Jun 23, 2009 at 7:37 PM, <Fancysmarket aol.com>wrote: Peter, 1 had another company look at the septic issue and there thoughts were that the system looks good. The floats are working just fine and they don't see any grease issues. (*keep in mind we had the grease trap pumped i twice) . The issue is 1.)water flow vs design or 2.)the failure of the field. I took them through the water usage scenarios and they seemed to know you and agreed it was probably not the issue. They are going to look at the plans, ' but their main focus seems to be on the black plastic trays that we put down in the field. "Something has gone { terribly wrong in the field"for it to back up so fast after installation. It could be soil issues but are surprised with such a good perk score. They really don't see many options other that tearing up the field and re-doing it. I am going to schedule this with Joey but wanted to give you a heads up. I want to talk to joe about waiting until September, but I want his opinion. Any thoughts? i s j Brian An Excellent Credit Score is 750. See Yours in Just 2 Easy Steps! Peter T. McEntee PE-Principal Engineering Works, Inc. 12 West Crossfield Road Forestdale, MA 02644 Tel/fax(508)477-5313 Tuesday, June 30, 2009 AOL: Fancysmarket Page 1 of 1 Subj: Fancys Market-Osterville, MA Date: 6/3/2009 2:32:19 P.M. Eastern Daylight Time From: Fancysmarket To: dpottS@geomatrixllc.com Hi David, As you know from Peters e-mail, I have to come up with a solution immediately. I am now in the process of meeting with other septic companies and starting over. Peter mentioned that the testing has gone well and that I should contact you before Going anything else.. Are we a good candidate? How fast could we install? How long does it take before we see results?Any thoughts....let me know. Thanks, Brian Smith Shop Inspiron, Studio and XPS Laptops at Dell.com Tuesday, June 30, 2009 AOL: Fancysmarket i t DATE: 7/16/09 REC'd BY: SLC FEE $ FOR BOARD OF HEALTH MEETING MTG: AUG 4, 2009 PROPERTY: 699 MAIN STREET, OST—FANCY'S MARKET MAP/PARCEL: 141 —011 CONTACT: PETER MCENTEE PHONE# 508-737-4768 CELL: 508-477-5813 Variance Requested: NONE Repair of Failed Septic after 1 yr. Site Specific Piloting Approval for: I/A System to be added—"Soil Air System" Pete will bring in plan. NO j7 JE _� W Uj v i °FTHE TpN� Town of Barnstable Barnstable Board of Health BARNSTABM + 200 Main Street,Hyannis MA 02601 9 i639. 10� �ArED MA'S A 2007 OFFICE: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Junichi Sawayanagi Paul Canniff,D.M.D. BOARD OF HEALTH MEETING AGENDA Tuesday, August 4, 2009 at 3:00 PM Town Hall, Hearing Room 367 Main Street, Hyannis, MA I. Hearing - Septic: POSTPONED Francis and Barbara Ferguson, owners — 512 Whistleberry UNTIL SEP 8, 2009 Drive Marstons Mills — bedroom count. II. Hearing — Housing: POSTPONED Francis Wurzburg - 140 Willimantic Drive, Marstons Mills- UNTIL SEP 8, 2009 ceiling height. III. Septic Variance (New): A. Peter McEntee, Engineering Works representing The 699 Main Street, LLC - Fancy's Market— 699 Main Street, Osterville, Map/Parcel 141-011, 0.17 acre parcel, approval requested for I/A Soil Air System on failed septic. III-B. ADDITIONAL: Food (Cont.): . �;7_ British Beer Company— results of grease logs. —J IV. Variance — Food (New): Caffe Gelato Bertini, 20 Pearl Street, Hyannis, new owner, two variances requested - toilet facility (1 provided) and grease trap variance, same menu as previous, no indoor seating. V. Informal Discussion: Peter Sullivan, Sullivan Engineering representing Ruth Wells, owner— 35 Navigation Road, West Barnstable, Map/Parcel 156 — 056. VI. Septic Variance (New): Glenn Harrington representing Steven and Nancy Costello — 255 Scudder Road, Osterville, Map/Parcel 139-014, 0.45 acre parcel, two non-environmental variances. , Vll. Proposed Revision to procedure of variances. Page 1 of 2 BOH Aug 2009 II VIII. Correspondence: A. Concerned neighbors of Stewart Creek B. Christine Tuck, 379 South Street, Hyannis- Veteran's Outreach Center Page 2 of 2 BOH Aug 2009 �^ • 10 BARNSTABLE CO^Y of BAR,1, DEPARTMENT OF HEALTH AND THE ENVIRONMENT SUPERIOR COURTHOUSE p Y� POST OFFICE BOX 427 vJ BARNSTABLE,MASSACHUSETTS 02630 CHUSti�� August 4, 2009 To: Barnstable Board of Health From: George Heufelder Re: Application before you to use Soil Air TM for market. Board Members: I understand that you may have before you an application to apply the SoilAirTM technology to a market in Osterville. This is the same technology that the.County applied at the Second District Courthouse under a site-specific Piloting Approval from DEP. To dispel any confusion,please understand that the market application before you is not under the County aegis, but is a private party application, and the following is advice and opinion only as your Chief County Health Officer. Summary • The soil absorption system at Fancy's Market has prematurely exhibiting signs of failure • A representative from Geomatrix, the company that sells the Soil Air TM technology has investigated the feasibility of trying the technology to reduce the fats-oil-grease and organic biomat so that the hydraulic function can be restored. • The engineer has been advised to apply for a site-specific Piloting Application through DEP for applying the technology in this situation: • That approval needs local BOH approval first • The applicant is presumably before you to obtain that approval before he proceeds to DEP. I would advise the following: • That the engineer provides evidence that the DEP Pilot Approval has been obtained prior to issuance of the Disposal Works Permit. • In your local approval you should stipulate the ponding-level observation frequency for the system be at least 2X per week and that the level be recorded in table form and reported to the Board of Health agent on a monthly basis. • That all pumping of the system be reported to the Health Agent within 24 hours of occurrence. • All alarms are reported to the Health Agent within one working day of the occurrence. Alternately, you could allow the installation of the systems, since it is basically enhancing the ventilation of a soil absorption system under a parking lot,provided that the applicant prov%de documentation that the Pilot Application has been submitted with all fees and that should it be denied the applicant shall remove the air blower within 24 hours of the notice of application rejection. For your information, the application of this technology at the Second District Courthouse appears to be beneficial in maintaining the hydraulic capacity of that system, which was exhibiting signs of hydraulic "fatigue". While our Department does not endorse the use of.the system, we are presently investigating its efficacy at the Massachusetts Alternative Septic System Test Center and elsewhere, and we are following the progress of the technology through the Massachusetts regulatory pathway with interest. Should you have any questions regarding our advice in this matter, please do not hesitate to ask. Sincerely, George Heufelder MS, RS ... Engineering Works, Inc. 12 West Crossfield Road, Forestdale, MA 02644 Tel/Fax(508)477-5313 July 21, 2009 Barnstable Board of Health 200 Main Street Hyannis, MA o2601 Re: 699 Main Street, Osterville, APN: 141-011 (Fancy's Market) Dear Board Members: On behalf of my client, Brian Smith, I am requesting Site Specific Piloting Approval to install a SoilAir TM system at the subject site to restore a soil absorption system (SAS) which is prematurely failing. Water usage at the facility suggests that the system has been receiving sewage flows that approximate the design flow and are less than the calculated flow provided by the soil absorption system. Observation of the Septic Tank, Grease trap and soil SAS have been made by this engineer and others. It appears as if the failure may be due to high organic content being introduced to the system. Further investigation of the SAS was performed by a representative of Geomatrix LLC to determine whether the SoilAir TM system might be a viable solution to restore the SAS. A core sample of the floor of the SAS was taken from an observation port located at the distal end of an SAS lateral. A thick emulsion had formed over the bottom of the SAS and the sample was taken to the lab and treated with the SoilAir TM technology. The sample showed improvement and was subsequently restored to natural sand. The current SAS occupy's all of the available area on the lot without requesting a variance. To remove the existing SAS and re-install another SAS without treatment seems futile. A hope the Board considers this request for remediation. I believe that it is the most cost effective and least disruptive way to address the problem. .� F� ,.. Q Sincerely, it Peter T. McEntee P.E. f TM systems Restoring and Enhancing Leachfieid Pefformance Technical Description December, 2005 Soi]Air is a trademark of Geomatrix,LLC Copyright 2005 Geamatk,LLC Introduction The SoilAir System is a recently patented process that is quickly gaining the acceptance and respect of the onsite wastewater treatment community. The SoilAir system can rejuvenate subsurface wastewater infiltration systems(SWIS)that have failed due to organic buildup on the soil interface(biomat). Additionally,the SoilAir system can improve the long-term acceptance rate(LTAR) and increase the treatment efficiency for many wastewater constituents. The SoilAir system consists of applying supra atmospheric air pressure to the SWIS. This results in oxygen flowing through the SWIS and out into the surrounding soil. Through this process, the biomat is transformed from anaerobic to aerobic. The aerobic and facultative microorganisms that flourish in this well aerated environment can then reduce the thickness of the biomat through their metabolic activity. Furthermore,the aerobic biomat is significantly more efficient at treating wastewater than conventional anaerobic biomats(Potts et al., 2004;Amador et al. 2005). To date, SoilAir systems have been utilized on approximately 100+sites. Systems are operating on new and existing SWIS including pipe and stone,plastic chambers, concrete galleries and dry wells. The SoilAir system has rejuvenated SWIS serving single family residences,restaurants, community systems, and numerous other commercial establishments; including those with high biochemical oxygen demand(BOD)and grease accumulations; some systems are over fifty years old. This has been accomplished in a wide range of climates and soil conditions. Oxygen concentrations and the impact on the SWIS It is commonly thought that oxygen concentrations in the soil adjacent to deep (>6 feet) SWIS are limited, oxygen in soils shallower than this are generally not believed to be limiting. In reality, although oxygen concentrations at depth do generally diminish, oxygen concentrations in the soil surrounding even the shallowest SWIS rarely match what is present in the atmosphere (21 Unfortunately, the oxygen transfer rate of the soil rarely meets the BOD of the wastewater, except in the most lightly loaded SWIS. This oxygen deficit results in the gradual buildup of biomat. When the biomat develops,it is typically significantly less permeable than the soil the SWIS is installed in. With the SoilAir system, soil oxygen levels adjacent to even deep, heavily loaded SWIS can be maintained at 21%. This is more oxygen than is typically present in soils just 6 inches below the surface of a golf green during the growing season, as is shown in Figure 1. Geematk,LLC 2 f Figure 1 Seasonal Soil Gas Levels @ 6" t, 6 20 5 d 4 O x 15 3V ,0 O 2 o p 1 10 0 Spring Sunrrer Fall Winter —m-- o2 Season -- - co2 Figure 2 Oxygen Uptake Test lVbhe ac,M Comnnity System#s 25 - - -- 77 20 � 15 f x 10 C2%b,vd.1�2a 5 i 0 Elapsed Time(hours) Geematrix, LLC 3 I Figure 2 shows the soil oxygen levels at 1.5 to 2.5 feet(MP-1S) and 15 to 20 feet(MP- 1D)below a SWIS during a SoilAir pilot study. The initial oxygen levels in both monitoring points are 0.0%by volume(%). Oxygen levels in MP-1 S reach 21%within 6 hours of starting the SoilAir pilot unit. Oxygen levels in MP-11)reach a high of 10%, after 27 hours of air injection. Once the SoilAir pilot unit is turned off, oxygen demand immediately exceeds oxygen supply. Within a few days,the oxygen provided by the SoilAir pilot unit is completely consumed. SWIS designers routinely assume that soils in the vadose zone inherently have high concentrations of oxygen present in the soil pore space. To illustrate how this is an incorrect assumption, groundwater on this site was greater than 25 feet below the SWIS. However,the background oxygen concentration was 0.0%at depths of 1.5—2.5 and 15—20 feet below the SWIS. Hydraulic loading rates must not only take into effect the hydraulic capacity of the soils,but the capacity of the soil to transfer oxygen. When oxygen concentrations adjacent to the SWIS are increased to 21%, it results in the oxidation of historic biomat accumulations and the subsequent reestablishment of hydraulic capacity. Furthermore,maintaining 21% oxygen in the soil pore space adjacent to the SWIS allows the LTAR to approximate that of the native soil it is installed in. The practice of resting SWIS is very similar to the SoilAir process. Resting is the only rejuvenation method endorsed by the U.S. EPA "Resting is an effective method to rejuvenate hydraulic capacity of soil infiltration surfaces"(Sharpe et al., 1984). When SWIS are rested, oxygen supply has an opportunity to catch up with oxygen demand, resulting in the reduction of biomat and the restoration of the infiltration capacity. "Extended periods of resting at regular intervals is effective in preventing excessive soil clogging and restoring clogged infiltration surfaces of SWIS"(U.S. EPA,2002). The SoilAir system simply accelerates this natural resting process,without the need for temporarily diverting the wastewater. Wastewater and air flow are simply alternated to the SWIS to mimic a rest interval on a daily basis. Comparison of other SWIS rejuvenation technologies SWIS have historically been outfitted with various aerobic treatment units(ATU)in an attempt to meet the BOD and unclog the excess biomat. This approach has met with some limited success. When wastewater is aerated, even in the most efficient, modern publicly owned wastewater treatment plant(WWTP), sludge/biosolids are generated, not eliminated. Most ATU do not operate at anywhere near these efficiencies. Even the WWTP must remove this sludge and landfill, incinerate, land apply or compost it. Land application and composting exposes this sludge to 21%oxygen, and in this environment the sludge can be further broken down. This is the same condition that the SoilAir system creates under ground. Getmatk,LLC 4 However,when the sludge is saturated with water oxygen concentrations are limited to the solubility of oxygen in water. In a conservative estimate at 55°F,this is a maximum of 10 parts per million(ppm)or 0.001%. When the sludge is exposed to air, 21% oxygen,this is approximately 21,000 times more oxygen than can be supplied under water. 21,000 times more oxygen in air than water is the primary reason why the SoitAir system is effective at reducing the thickness of biomat; and why ATU produce sludge. The SoilAir process is effectively insitu composting of biomat. The SoilAir system is often confused with the Terralift8 process. The Terralift process consists of injecting plastic pellets entrained in a blast of air into the soil adjacent to the SWIS to create fractures and fissures though the soil,through the biomat and into the SWIS. These newly formed pathways allow the wastewater to rapidly drain out of the SWIS. However, in most situations,these pathways provide but a fraction of the original infiltrative surface area that has already been shown to provide insufficient hydraulic capacity. This technology rarely provides a long term solution. Another SWIS rejuvenation strategy is to inject hydrogen peroxide and other strong oxidizers such as acids into the SWIS. When this is done,the biomat is chemically oxidized. However, as this reaction is occurring,the biomat and soil interface"boil"; causing the coarser grained particles to sink and the finer grained particles to rise. Although this can allow the wastewater to infiltrate the soil for a period of time,the beneficial results are often short lived. This uniform layer of fine grained soil particles will also develop a biomat and the combination of the two is even less permeable than the original condition. Soil pore space oxygen concentrations and the effect on treatment Soils are a highly effective media for wastewater treatment,providing filtration,buffering capacity, large surface areas for microorganisms,temperature stability, moisture retention, and aerobic and anaerobic regions in close proximity to one another. No other wastewater treatment system can consistently match this combination and consistent performance. The only deficiency of heavily loaded soils is the limited oxygen supply. When the SoilAir system is operating, air travels out of the SWIS and into the surrounding soil through the capillary tubes and macropores. This air movement displaces gases such carbon dioxide,methane and hydrogen sulfide that have built up in the soil pore space and replaces them with air. The air contains oxygen for utilization by the aerobic and facultative microorganisms and for biochemical reactions. An additional benefit is the air movement also helps to more uniformly distribute both free water and water vapor in the soils adjacent to the SWIS, significantly diminishing the potential for saturated flow conditions to exist. High oxygen concentrations in the soils surrounding the SWIS allow for a higher level of wastewater treatment; specifically, increased removal of ammonium,nitrite,nitrate,total nitrogen,phosphorus, BOD and pathogens such as fecal coliform. Geomatrix,LLC 5 f f i r The introduction of air into the soil adjacent to the SWIS results in significantly greater oxidation of ammonium to nitrate than occurs in the absence of SoilAir. Once nitrified, the denitrification process can proceed and the net result is additional total nitrogen removal over what occurs in the absence of SoilAir. (Potts et al., 2003;Amador et al., 2005). i Enhanced total phosphorus removal will result when iron is present in well-aerated soil (Robertson,2003; Zanini et al., 1998). Increased total phosphorus removal has been observed in aerated test lysimeters containing native soil with iron in the parent material, as compared to nonaerated lysimeters in the Westbrook, Connecticut test facility. For instance, in four replicate test lysimeters operating for approximately eight months,the mean influent concentration of total phosphorus was 8.7 ppm. The mean total phosphorus value for the aerated and non-aerated lysimeter was 1.5 and 2.5 ppm respectively. The high soil oxygen levels resulting from the SoilAir process dramatically improves the BOD removal efficiency of the soil adjacent to the SWIS. After 1 foot of aerated soil, 100%of the BOD was consistently removed. As a comparison, 1 foot of nonaerated soil removed between approximately 15 and 82%of the BOD (Potts et al., 2004; Amador et al.,2005) Soils adjacent to SWIS with SoilAir provide for significantly greater removal efficiencies of fecal coliform,ranging from one to four orders of magnitude greater than those without SoilAir(Potts et al., 2004;Amador et al., 2005). Increased removal is largely attributed to less saturated flow conditions/increased straining, intermicrobial predadation and antagonistic micro flora. SoiMir system field application and components The SoilAir system installation necessitates that the septic tank cleanout is uncovered to allow for cleaning and inspection of the septic tank and related components. On gravity systems,the effluent line between the septic tank and the leach field is exposed directly downstream from the septic tank. A portion of this line is removed to facilitate vacuum dewatering of the SWIS and the installation of subsurface SoilAir components. These subsurface components include an air backflow prevention device to pneumatically isolate the SWIS and a float switch to monitor septic tank levels and control blower operation. When the SWIS is outfitted with a pump station, a check valve is installed on the pump discharge line, and the SoilAir system is configured to turn off the blower prior to energizing the pumps. The aboveground SoilAir components include a blower and controller,both in weatherproof enclosure installed in an unobtrusive location within 200 feet of the septic tank. An air supply line connects the subsurface components described above to the blower. Lastly, power and phone lines are run to the equipment enclosure location. Gepmatk,LLC 6 The SoilAir system is equipped with a microprocessor based controls package. This allows for a wide range of operational schemes to be accommodated. When rejuvenating a failed septic system, the blower is typically programmed to operate continuously, stopping only to allow a dose of wastewater to flow from the septic tank into the SWIS. As the excess biomat is oxidized,the system back pressure will typically decrease. The microprocessor can sense this change and can reduce the duration and/or frequency of blower operation. Furthermore, changes in system back pressure are indicative of the relative hydraulic capacity of the SWIS; effectively a permeability test is conducted whenever the blower is operating. The microprocessor can also determine the volume of wastewater applied to the SWIS by tracking the number of doses per day. The control logic can be programmed to adjust system operation accordingly. A message can be forwarded to the service provider and property owner via the modem for uncharacteristic flows, such as a running toilet. Control logic based or manual adjustments to SoilAir system operation can be readily made via the modem or directly through the control panel. Maintenance All septic systems need management and routine maintenance. SWIS with SoilAir are no different. Maintenance can include inspection of the septic tank sludge and scum levels and any necessary pumping. Smoke testing,blower efficiency analysis and filter replacement are also typically performed. With automated systems should a component fail during the course of the year, the controller can notify a service provider. Maintenance programs have proven to be the most efficient and cost effective manner of ensuring proper system operation. If the blower becomes inoperable or the air filter clogs,the oxygen supply will once again become limited and the BOD may no longer be met. In time,the SWIS will again develop a restrictive biomat and no longer be able to handle the hydraulic load. Suitable uses of SoilAir for rejuvenation of failed SWIS The SoilAir technology is not suitable for all failed SWIS. Soils must be unsaturated and have sufficient hydraulic conductivity for the present hydraulic loading rate. A crude litmus test for the potential use of the SoilAir technology on any given site is the following: assuming a similar historical hydraulic load, did the SWIS function properly for at least one to two years? If the answer to this question is yes,the SWIS exhibits symptoms that are characteristic with biomat buildup. The SoilAir System will likely be effective at restoring hydraulic capacity. Balance BOD with oxygen supply for reliable performance Geematrix,LLC Y � . Present day design practices and federal and state regulations have addressed many of the historical deficiencies. The one remaining critical omission is providing a means to balance BOD with the oxygen supply. When this demand is met, unprecedented treatment efficiencies and hydraulic performance result. When this demand is not met, SWIS fail prematurely and treatment efficiencies suffer. This oxygen demand in the SWIS can only be consistently met through intermittent treatment outside of the SWIS, larger systems with uniform wastewater application or with SoilAir Systems. For more information contact: David Potts Environmental Scientist Geomatrix LLC 385 Roast Meat Hill Road Killingworth, CT 06419 860-663-3993 fax: 860-663-0324 Geematrix,LLC 8 SoilAir System with demand dosed pump station PUMP STATION MANHOLE COVER TO GRADE -Not to Scale- LIFT-OUT ADAPTER FROM SEPTIC TANK HIGH LEVEL PVC DISCHARGE ALARM TO LEACH FIELD 17 SNAP ON DIFFUSER i^" WEEP HOLE NZ CHECK VALVE PUMP PUMP FLOAT SOILAIR FLOAT PUMP BUILDING SEPTIC STATION TANK CHECK D-BOX VALVE i CONTROL PANEL H- Copydght 2006 GEOMATRO(,LLC Manufactured under one or mote afthe f.&Wng S O I LAI R patente:6,485,647,8,726,401,6,814,888, EQUIPMENT 88 8,887,383.6.93,905,8,959, 2,6,989,484 SollAlr System with demand dosed pump station GEOMATRIX,LLC Killingworth,CT SCALE NONE I REV. A DATE 9/8/06 IACAD No. PUMPSTATION.DWG DRAWN BY: ERP SHEET I OF I fEi �L� f , � MASTEK p77 ,. cyl a S,,V AC .......... ry `T I II V Models: I' VP215 ( 0 � User's Manual VP215EU (220-240\�Register your>{ roduct and get support at www.MyVacMaster.com v.201 a-11.o4 Thank you for purchasing the VacMaster®VP215 Chamber Vacuum Sealer. You are about to use one of the most powerful vacuum sealers a} available. With the help of the VP215, you will now be able to keep food fresh for longer in the refrigerator, freezer or pantry. The VP215 effectively removes air and extends freshness up to five times longer , than traditional methods. Our versatile and convenient machine can also`, be used to preserve and organize other items, like keepsakes or small, easy-to-lose items. Your VP215 will quickly become invaluable to all P` your packaging needs; it will never leave your countertop. I' The VP215 is a chamber vacuum system; which offers two distinct advantages over non-chamber, external suction units. First, a much higher level of vacuum can be achieved, which means a longer shelf life for foods that you package. Secondly, liquids and liquid-rich foods can r be effectively vacuum packaged. Foods like fresh meats, fish, soups, a stews and marinated vegetables are packaged quickly with ease and no mess. The VacMaster®VP215 is perfect for sous vide cooking. For your safety and protection, carefully read and folloanr;this guide. For 1 more information, please visit us at www.MyVacMaster.com. rife Table of Contents t.µ Safeguards................................................................................... 2 Tips ................3 Features.................................................................................................4-5 How To............................................................................................:....6-10 a Troubleshooting .......................................................... 11 Cleaningand Care................................................................................... 12 Vacuum Packaging Guidelines................................................................. 13 Parts ...................................................................................................14-17 Warranty and Registration .. i 8 ................... www.MyVacMaster.com • 800-821-7849 r i Important Safeguards For your safety, always follow these basic precautions when using a VacMaster®VP215 Chamber Vacuum Sealer: 1. Read all instructions in this User's Manual before use. 2. Do not use the VP215 near a heat source or on a wet or hot surface. 3. To protect against electrical shock, do not immerse any part,. Of the vacuum sealer plug or power cord in water or any other liquid. 4. Unplug the machine before cleaning or when not in use. - 5. . To disconnect, unplug the power cord from the electrical outlet. Do not disconnect by pulling on the cord. 6. Do not operate the VP215 if it has a damaged cord or plug. 7. Do not operate the VP215 if it malfunctions or is damaged: - Contact Customer Service at 800-821-7849. 8. Use the VP215 only for its intended use. 9. Closely supervise children when using any electrical appliance. Do not allow the VP215 to be used as a toy. 10. The VP215 (120V appliances only) has a grounded plug. Use only a grounded electrical outlet. To reduce risk of electrical { shock, do not modify the plug in any way. 11. Do not use an extension cord. 12. The power cord should not drape over a counter or tabletop, as the cord could be tripped over or pulled on unintentionally. 13. Do not place or operate near an electric/gas Purner or a heated oven. K: 14. Extreme caution and care must be used when sealing or handling any pouches containing hot liquids. , + I SAVE THESE INSTRUCTIONS I� www.MyVacMaster.com • 800-821-7849 i Important Tips • Vacuum packaging is not a substitute for canning. All perishables still need to be refrigerated or frozen. • Follow all food safety regulations as outlined by the FDA at www.FDA.gov. • Use only VacMaster®Vacuum Chamber Pouches and accessories. • Some fruits and vegetables may release gases, known as outgassing. When.packaging these fruits and vegetables, outgassing can cause the vacuum to be gradually lost over time Blanching or freezing before vacuum packaging helps prevent this from occuring. • Delicate foods can be frozen prior to packaging to protect them: from getting crushed by the vacuum. • Use VacMaster° Bone Guards to cover an jterNs sharp edges tt prevent pouch punctures. • Allow foods and liquids to cool before vacuum packaging. 11 • Avoid overfilling the pouch. Leave a minimum of 3" of space between the contents and the open end of the pouch. This is called head space. This will prevent spills during the vacuum sealing process. • To prevent wrinkles from forming in the seal, gently stretch the pouch flat along the seal bar before closing the lid. VacMaster® pouches are boilable, freezable, and microwavable When microwaving, it is important to pierce or make a small cu in the pouch. www.MyVacMaster.com • 800-821-7849 Features of the VP215 r ?. 5 O q 4> 7 x $_ 8 0 .. S E iS 1. Seal Pad 2. Lid Gasket 3. Power Switch 4. Vacuum Chamber f 5. Filler Plates - Used to occupy space in the chamber. The plates allow for faster vacuum. When more space is occupied, there is less '- air to be removed from the chamber. 6. Seal Bar 7. Lid Lock-This feature is used to keep the lid closed while the I machine is in storage. DO NOT USE while the machine is operating. 8. Control Panel I f www-MyVacMaster.com • 800-821-7849 Control Panel of the VP215 2 3 o.rs 4 0.075 VAC 0.035 1 o,ob o.oz upa o 5 6 7 1. Vacuum Gauge- Indicates the vacuum level inside the chamber. 2. Function Lights: Vacuum- Illuminates to adjust vacuum time as well as during tr vacuum process. During set up, adjust the vacuum time using the UP/DOWN Buttons. Gas-This model does not offer the gas flush option. Sealing- Illuminates to adjust vacuum time as well as during th sealing process. During set up, adjust the sealing time using t UP/DOWN Buttons. Cooling- Illuminates to adjust vacuum time as well as during tt cooling process. During set up, adjust the cooling using the U DOWN buttons. 2. Working Indicator Light_ Illuminates to indicate the machine is in use. 3. LED Screen (Time) - Displays current function or cycle time, measured in seconds. 4. STOP Button - Press to stop the cycle and immediately seal the pouch. This button will only work when the machine is in the vacuum process. 5. SET Button - Press to select the vacuum time, sealing time, or cooling time. Use with the UP/DOWN buttons. 6. UP/DOWN Buttons - Press to increase or decrease vacuum tirr sealing time, or cooling time. www.MyVacMaster.com • 800-821-7849 i Set Up - Adding Oil to the VP215 Please read all instructions before operating the VP215. r . L PORTANT: Oil must be added to machine prior to use. Make e the VP is turned OFF and unplugged before adding oil. Required Supplies. /2 quart of VACMASTER6 machine oil Empty oil bottle with spout k Phillips head screwdriver Adjustable wrench (not included) E r;= s Oil Fill Bolt Back of ., Housing 1 Oil Site f Cabinet Glass 4 1. Prepare the oil -The VP215 includes a maintenance kit that i contains a 1/2 quart of oil and an empty oil bottle_with spout. Fill l the empty oil bottle with oil. 2. Remove the back panel Using the enclosed Phillips head screwdriver,.remove the four screws from the back panel and take the panel off the machine. 3. Remove the oil fill bolt - Locate the oil fill bolt on the vacuum j pump and remove it using an adjustable wrench or similar tool. 4. Fill the pump with oil - Insert the spout into the open hole (oil fill bolt opening) and begin pouring the oil into the pump. Fill the pump until the oil level is at 1/2 to 3/4 in the site glass. This is approximately 3 - 31/2 ounces of oil. 5. Replace the oil fill bolt and back panel - Once the pump is filled with oil, screw the oil fill bolt back in place and put the back panel on the machine. j The VP215 Chamber Vacuum Sealer is now ready for use. I i w%v.MyVacMaster.com • 800-821-7849 Set Up - Starting the VP215 1. Attach the power cord and plug the machine into a grounded electrical outlet - Properly insert the electrical cord into the power outlet on the back of the machine and then plug the cord into the wall outlet. 2. Open the machine lid - Release the lid lock, located on the right side of the machine, and allow the lid to lift and remain open. IMPORTANT: Do not turn the machine on until the lid lock has been released.The lid lock feature is used ONLY to keep the lid closed while the machine is in storage. 3. Turn the power switch on -Turn +` the red switch on the left side of the ` machine toward the front, switching from the "0" to the "1" position. The LED Screen on the control panel will illuminate showing a F-_- symbol. Set'-:Up- Adjusting the VP215 Timing Controls Note: All timing adjustments must be made with the lid lock off and the lid open. To adjust/set the timing controls, press the SET button on the control panel until the required label (Vacuum, Sealing or Cooling) is illuminated. For each selection,.the current time setting will show on the LED Screen. All time settings are displayed in seconds. For initial testing, the time settings should be: Vacuum Time - 40 seconds Sealing Time - 1.2 seconds Cooling Time - 2 seconds To change the settings, please read the instructions for each control on Page 8. www.MyVacMaster.com 9 800-821-7849 Set Up - Adjusting the VP215 Timing Controls Vacuum Time: To increase or decrease the vacuum time, press the SET button until VACUUM is illuminated and then use the UP/DOWN buttons to adjust the vacuum time accordingly. The time setting will display on the LED Screen on the control panel. Note: Filler plates can be used to reduce the vacuum time required. Place the I filler plates inside the chamber as desired. Filler plates occupy space, leaving less air to be removed from the chamber. If you require.more space inside the chamber, remove the filler plates to accommodate your product. V Sealing Time: To increase or decrease the sealing time, press the SET button until SEALING is illuminated and then use the UP/DOWN buttons to adjust the sealing time to accommodate your application. It is recommended that you make adjustments in 0.1 second increments to avoid melting the pouch. Note: For thicker pouches,you should increase the seal time in 0.1 second increments until the pouch seals completely. In addition, for thinner pouches,you should decrease the seal time in 0.1 second increments to avoid over-sealing the pouch. jCooling Time:To increase or decrease the cooling time, press. the SET button until COOLING is illuminated and then.use the UP/ DOWN buttons to adjust the cooling time accordingly. Note: The VP215 settings will always default to the most recently used settings on the machine. TIP. To prolong the life of your seal bar, set the cooling time to twice the sealing time. I ; i i i I www.MyVacMaster.com • 800-821-7849 i Use the VP215 Chamber Vacuum Sealer Note: After setting the timing controls,press the SET button until the function lights 'on the control panel are no longer illuminated. The machine will not start until all function lights are off. 1. Select a vacuum chamber pouch Select the proper size of vacuum chamber pouch for the prod- uct that you are packaging. Make sure that the mouth of the pouch does not exceed the length of the seal bar and make sure the entire pouch fits inside the chamber. Allow 1" to 2" of extra headspace at the top of the pouch to ensure a quality, air-tight seal. The VP215 accepts vacuum chamber pouches up to 10"W x 13"L in size. 2. Fill the pouch and place inside the chamber Fill the pouch with the product to be vacuum packaged and place the pouch inside the chamber. Keep pouches that contain liquids or wet product below the height of the seal bar. Lay the pouch flat inside the chamber, with the opening of the pouch across the seal bar. Make sure that the pouch lies flat across the seal bar and is free of wrinkles. Note:The entire pouch, including the opening,must remain inside the chamber. 3.1 Close the machine lid to vacuum and seal Close the lid and press down firmly for 2-3 seconds or until the vacuum gauge begins to move. Vacuum Cycle Cooling.Cycle Runs for a set time-counting down to zero . Runs for a set time-counting down to zen Sealing Cycle Lid Release Runs for a set time-counting down to zero Indicates the end of the process. OAMM CF . www.MyVacMaster.com • 800-821-7849 i Use the VP215 Chamber Vacuum Sealer 4. Inspect the pouch When the lid opens, remove and inspect the pouch. Vacuum confirmation - Check the quality of the vacuum by looking at the tightness of the pouch and the product. Look for air pockets or air leaks. If you notice that the product is not i vacuum packaged tightly, then increase the vacuum time by 5 seconds and vacuum and seal again. Seal confirmation— Inspect the pouch seal. A positive seal f will appear clear upon inspection. If the seal is spotty or incom- plete, increase the seal time by 0.1 second. If the seal appears white or milky, decrease the seal time by 0.1 second. Once the settings are determined for your application, vacuum and seal again. If the product is vacuumed and sealed tightly, then the process is complete. 1 I i i i i www.MyVacMaster.com • 800-821-7849 Troubleshooting VP215 will not turn on - • Make sure the machine is properly plugged into a grounded outlet: • Check the power cord for tears and frays. Do not use this machine if the power cord is damaged. ` • Make sure the power switch is turned on.The LED screen will be illuminated when on. • If you see `Fi' displayed on the LED screen and the machine will not function, make sure the lid is open and turn the power off. Turr the machine back on and it should return to working order. VP215 does not pull a complete vacuum with pouch - • The vacuum time may not be set high enough. Set the vacuum time higher and vacuum again. ` • To vacuum and seal properly, the opening of the pouch must be within the vacuum chamber. For detailed instructions, refer to "Ho, To Use the VacMaster®VP215 Chamber Vacuum Sealer". i The seal bar, lid gasket and vacuum pouch ne9d to be clean, dry and free of debris for the vacuum process to be successful. Wipe surface of the seal bar, lid gasket and the inside of the pouch and try again. Vacuum pouch loses vacuum after being sealed- • Sharp items can poke small holes in pouches. To prevent this; cover-sharp edges with a paper towel or VacMaster®Bone Guard and vacuum in a new pouch. • Some fruits and vegetables can release gases(out-gassing) if not properly blanched or frozen before packaging. Open the pouch. t If you think food spoilage has begun, discard the food. If food spoilage has not yet begun, consume immediately. If in doubt, discard the food. I VP215 is not sealing pouch properly- • The seal time may not be long enough. Increase the seal time an, try again. • Pouches will not seal if any moisture, food particles or debris are present in the seal area. Wipe the inside of the pouch clean and try again. • Pouches must be properly placed along the seal bar. Make sure II the entire pouch is over the seal bar and there are no wrinkles in 1 pouch material. !� I If problems persist,contact customer support at 800.821.7849 for further assistant www.MyVacMaster.com • 800-821-7849 i I Cleaning and Care . • Disconnect the power cord from the electrical outlet by unplugging it. DO NOT disconnect by pulling on the cord. • DO NOT immerse in water or spray directly with liquid. • Check the Vacuum Chamber and Gasket, making sure they are clean and free of debris. If needed, use a clean, damp cloth with mild soap. a. Wipe the vacuum chamber clean. b. Wipe the gasket clean. c. Wipe the seal area clean. { Do not store the VP215 outside. I + DO NOT use any acetone-based or abrasive cleaners on the lid or other plastic parts. Only clean lid with a damp cloth and mild soap. i� I I I j www.MyVacMaster.com • 800-821-7849 Vacuum Packaging Guidelines • Follow all food safety regulations as outlined by the FDA at www.FDA.gov. • Vacuum packaging is NOT a substitute for canning. • Vacuum packaging cannot reverse the deterioration of foods. • Vacuum packaging is NOT a substitute for refrigeration or freezing. • Some fruits and vegetables may release gases, known as outgassing. When packaging these fruits and vegetables, outgassing can cause the vacuum to be gradually lost over time. Blanching or freezing before vacuum packaging helps prevent this from occuring. NOTE.•Due to the risk of anaerobic bacteria,soft cheeses, fresh mushrooms, garlic and onions should never be vacuum packaged. - It is critical that food handling and storage are maintained at low jtemperatures. You can reduce the growth of rrricroorganisms at temperatures of 340F or less. Freezing at 0°F will not kill -microorganisms, but reduces the chances of them growing. For long-term food storage, always freeze foods that.have been vacuumed packaged. NOTE Beef and other proteins may look darker after being vacuum packaged. This is due to the removal of oxygen and is not an indication of spoilage. • All perishable foods must be refrigerated or frozen. i I I www.MyVacMaster.com • 800-821-7849 I Parts Information 5 6 No. Description Oty Part Number 1 Lid Screws 4 2 Upper Plate for Lid 2 3 Lid 1 979201 4 Lower Plate for Lid 2 5 Lid Gasket 1 979425 6 Holder for Seal Pad 1 979225 7 Seal Pad(Brown) 1 979226 Ji I I I I www.MyVacMaster.com • 800`821-7849 Parts Information i 18 17 16 1-5 14 12 11 20 IrJ 23 r 8 7_ 6 s _ 24 26 4 u+r 3 a`� t 28 "sib 2 _�� t s = 30 $* 44 trt h 43 � 3i 32 2r y 2 34 33 �— '' � � 36 35 .37 =yam t;1: 41 48 ' 38 39 .� www.MyVacMaster.com • 800-821-7849 � Parts Information No. Description oty Part Number 1 Machine Housing 1 2 Foot Rubber 4 979159 3 Pump Mount Spring 1 979218 4 1 Housing Cover 1 5 Vacuum Pump 1 979215 6 Hose Barb Fitting 1 7 Connector 1 979245 a .. 8 Oil&Gas Filter 1 979244 9 Air Filter 1 979250 10 15 Amp Fuse 1 979209 11 Socket Plug with Fuse 1 12 Bracket for Socket Plug 1 13 Check Valve 1 14 Hose to Check Valve 1 979157 15 Hose Barb Filter Exhaust 1 t 16 Air Inlet Fitter 1 17 Bracket for Air Inlet Filter 1 4 18 Hose Barb for Air Inlet Filter 1 19 Relay Contactor 1 979141.' 20 Solenoid Valve Pack 1._. 979261 21 Seal Transformer 1 979240 22 Chamber Support Arm 1 23 Control Transformer 1 979139 24 Support Arm Spring 1 25 Solenoid Valve Hose 1 979156 26 Check Valve O-Ring 1 27 Bracket Support Arm 1 u 28 Relay Timer 1 979136 29 Mounting Blocks Relay 4 30 Power Switch 1 979138 31 Bracket for Power Switch 1 979137 32 Control Cable Plug 1 979128 33 Cable Plug Screw 2 34 VacMaster Panel Decal 1 979130 35 Vacuum Gauge 1 979126 36 Control Mounting Panel 1 979125 37 Control Panel Decal 1 979122 38 Settings Decal 1 979122 39 Decal Model VP215 1 979122 40 Circuit Board 1 979129 41 Lid Latch 1 979170 42 Control Cable 1 979242 43 Motor Spring Support 4 979217 44 Bottom Housing 1 www MyVacMaster.com • 800-821-7849 F Parts Information ' 1 It 5 4 3 ' s� r'llTl • -7 W _* 8 21 13 14 9 10 11 12 16 17 18 i 19 20 No. Description x Oty Part Number 1 Chamber 1 2 Vac Port(White) 1 3 Plate.Assembly 2 4 Hinge Pin 2 5 Spring 2 6 Hinge 2 7 Roller Pin 2 8 Hinge Connecting Eye 2 9 Hexagon Hinge Stop 2 10 Roller 2 11 Bumper Hinge 2 12 Screw 2 13 Plate Lid Pressure 2 14 Mount for Micro Switch 1 15 Micro Switch 1 979255 16 Lid Spring 2 17 Spring Adjustment Eye 2 18 Piston for Seal Bar(large) 2 979380 19 Hose for Piston 2 20 Tee for Piston Hose 1 21 Complete Seal Bar 1 979200 21 Seal Tape(Tape Only) 1 979410 www.MyVacMaster.com • 800-821-7849 Limited Warranty ARY; Inc., a distributor and manufacturer of vacuum packaging and other machines (collectively,the"Goods"), extends to the purchaser of the Goods a Limited One Year Warranty,from the receipt of the Goods,under terms and conditions set out herein. All:Goods sold by ARY, Inc. are warranted to be free from defects in material and workmanship at the time of delivery to purchaser. Defective material may be I returned to ARY, Inc.after inspection by an agent of ARY, Inc.and upon receipt from ARY, Inc.of shipping instructions specific to the defective Goods authorized by ARY, Inc.to be returned.ARY, Inc.at its sole option, may either(i)replace or repair any defective materials and workmanship(and return the Goods to purchaser without charge), (ii)refund the purchase price,or(iii)grant a reasonable allowance U with the foregoing procedure. } This warranty is subject to the following limitations: i.ARY, Inc.'s responsibility and the purchaser's exclusive remedy under this warranty is limited to the repair or replacement of defects in material and workmanship,. ,.. refund of the purchase price,or grant of a reasonable allowance on account of such defects,all as set forth above.ARY, Inc. is not responsible for any consequential' damages resulting from the breach of this or any other express or implied warranty with respect to the Goods. ii.This express warranty is the only warranty applicable. It excludes all other express oral or written warranties and all warranties implied by law with respect to the Goods, including any warranties or merchantability or fitness for a particular ' purpose. iii. Every claim under this warranty shall be deemed waived by purchaser unless made in writing within one(1)year of the receipt of the Goods to which such claim F relates. iv.This warranty,as to the Goods, is void(a)to repairs made by anyone other than ARY, Inc.without prior authorization from ARY, Inc., (b)to performance of any system of which ARY, Inc.'s Goods are a component part,(c)to deterioration by corrosion or any cause of failure other than defect of material or workmanship,(d)to an y components of the Goods,including,without limitation,Teflon tape,lid gaskets and seal wire,or(e)if any of the Good or parts thereof have been tampered with or altered by someone other than ARY, Inc.,or subjected to misuse, neglect,abuse,or misuse in application. ARY, Inc.'s maximum liability hereunder,arising from any cause whatsoever,whether based in contract,tort(including negligence),strict liability,or any other theory of law,shall not exceed the purchase price.A suit based on any aforementioned cause of action must be commenced within one year from the date said action accrues. Register your product and get support at www.MyVacMaster.com/warranty.htm www.MyVacMaster.com • 800-821-7849 ARYI nc. ARY, Inc. RO:Box 412888 Kansas City, MO 64141 www.MyVacMaster.com i 80M21.7849 i i I .. All Rights Reserved. VACMASTER®and VacStrip®are trademarks or registered trademarks of ARY, Inc. in the United States and other countries. v.2014-1' —/Itnw�Q �� CPr�,�PU lr'Glfew��t'r ? C F de Pins. r^ i q o 9/7/2010 Town of Barnstable Board of Health ' 200 Main Street, Hyannis,MA 02601 Monitoring Plan Fancy's Market 699 Main Street, Osterville Dear Members of the Board Please find enclosed a copy of the State approval letter for Remedial use of the Sludgehammer ABG S-86 along with a proposed monitoring plan. n� The System meets the criteria of 310 CMR 15.284(2) (listed below with answers in bold) V (2)Remedial use of an alternative system shall be allowed where the Department finds that all of the following conditions are met: v a (a)the proposed use of the alternative system is for upgrade of a failed, failing or nonconforming existing system(s); proposed use is for upgrade of failing system (b)the design flow is less than 10,000 gallons per day, and there is no increase in design flow to be served by the proposed alternative system;Design flow is 474 gpd(SAS area provided is 638.5 gpd) p �I o (c)the applicant has established, through evidence of effective past performance of the ^ alternative system over a period of at least one year of general usage in other states where 0 relevant physical and climatological conditions are similar to those in Massachusetts, that the alternative system will provide a level of environmental protection 1. at least equivalent to that of a system designed and constructed in accordance with 310 CMR 15.100 through 15.293, for use where connection to a sewer system is not feasible, or 2. at least equivalent to a sewer system, for use where connection to a sewer system is feasible. The Department shall waive this requirement in situations,where such evidence is already on file with the Department for that system. When relying on system performance in other states, all available information including but not limited to a copy of the other state's written approval, testing and performance data shall be provided. DEP approval(transmittal number X228133) for remedial use& (transmittal number X228156)for general use �T SLUDGEHAMMER ABG S-86 2 Year Monitoring Plan September 2010 thru September 2012 For the first month after installation: Weeklv Inspections/Monitoring(minimum of 4 weeks) 1. Monitoring of SAS liquid levels by means of data logger with a minimum of 4 logging events per day 2. Field sampling of effluent at inlet of pump chamber testing for PH, DO,Turbidity and Temperature 3. Field sampling of effluent at D-Box for PH, DO,Turbidity and Temperature 4. Inspection of Septic Tank for sludge and scum levels S. Inspection of Grease Trap for depth of grease 6. Inspection of all filters 7. Inspection of ABG unit and compressor 8. Inspection of Pump Chamber sludge and scum levels 9. Water use readings 10. Pump run times and override events(making adjustments as required) At the end of 4 weeks a lab sample will be pulled testing for BODs and TSS along with field sampling for PH, DO,Turbidity, and Temperature. At the end of one month and successful operation of upgrade the above monitoring plan will move to a quarterly schedule with lab samples for Bods and TSS sampled at the D-Box. Quarterly schedule to remain in effect for the next two years,at which time owner may request reduction in monitoring/sampling from the Board of Health. Data Logger events to be reduced to one daily logging of SAS levels. If during a quarterly inspection,system fails any of the field tests,weekly monitoring will be placed in effect and reason,for failure corrected.Weekly monitoring to continue for a minimum of two weeks after passing field tests. Passing field tests are 1. DO-greater than 2 mg/I 2. PH—between 6&9 SU 3. Turbidity—less than 40 NTU 4. No offensive odor 2/25/2010 (d)the local Approving Authority has found that conditions 310 CMR 15.284(2) (a)through(c) are satisfied; ' and (e)the applicant has made arrangements through contract with a vendor or in another manner acceptable to ' the local Approving Authority and the Department to ensure that necessary operation and maintenance of the alternative system will be performed appropriately. O&M agreement based on enclosed monitoring plan to be signed by owner prior to COC. i i If I can be of further assistance please feel free to contact me at 774-313-6602 cell or at my office 508-776- 6219 or by email tiw•,._r._,iln:�.tuii,�?c_�;��,.�7si;_r�eL r f { i Sincerely { Winston.A. Steadman IT All Cape Environmental Inc. i i i i i i i I SLUDGEHAMMER ABG S-86 Monitoring Plan September 2010 thru 2011 Weekly(minimum of 4 weeks) 1. Monitoring of SAS liquid levels by means of data logger with a minimum of 4 logging events per day 2. Field sampling of effluent at inlet of pump chamber testing for PH, DO,Turbidity and Temperature 3. Field sampling of effluent at D-Box for PH, DO,Turbidity and Temperature 4. Inspection of Septic Tank for sludge and scum levels 5. Inspection of Grease Trap for depth of grease 6. Inspection of all filters 7. Inspection of ABG unit and compressor 8. Inspection of Pump Chamber sludge and scum levels 9. Water use readings 10. Pump run times and override events (making adjustments as required) At the end of 4 weeks a lab sample will be pulled testing for BODs and TSS along with field sampling for PH, DO,Turbidity, and Temperature. At the end of one month and successful operation of upgrade the above monitoring plan will move to a quarterly schedule. Data Logger events to be reduced to daily logging. If during a quarterly inspection, system fails any of the field tests,weekly monitoring will be placed in effect and reason for failure corrected. Weekly monitoring to continue for a minimum of two weeks after passing field tests. Passing field tests are 1. DO-greater than 2 mg/I 2. PH—between 6&9 SU 3. Turbidity—less than 40 NTU /J ALL CATS S W R o0 HEHrAL MCI o{t 1T�► �Q of . ► . . $B��iR [�'i3 V V CA y U bA 4-. a> V1 C Q K s O 00 Q'i .O iU �� O O �O ca 5) C v CL id G a Ricd zs o n n R a> � � p] � M � 4-. > ta O N th C. L! C Y O b Y u ¢ i > L 3 O Y a> a> o c A eL, 3 m o aVi m si o v 3 E ca y rL ' �O RbD ,� cC ;,� ON O v � 2 U G L 'a � �-+ .� > '� U y U p O N O U -p of R C coco ct aS cd Q C R R C �n _ - C/] > N .O bA 'R O O h cC (AA O O a1 O O •N C C •C L. y, 'b !�; LQ L '� - c > Q O W,> y u Q W a> O O cAtd N O O O' aR> 3 C co u O 3 o�yo cz _ oo f-' G� Q N �, CG p ..� U D G H �• � cC � U f" W .� ca �n V} � � .-; >, sU., � r cn `�� Q i i e ji W/o) �► :.�_l Ail Cape Environmental Inc.- P.O.Box 235 Yarmouth.Port,MA 02675-0235 Town of Barnstable Board of Health Attn; Thomas McKean 200 Main Street Hyannis, MA. 02601 t. ,� • '� `� 'ff �.. �i �� -.� r �� -, '��, i � /� � . �� '� �� y ,y,.r. -� �f � A'\ - "� - - - - '.x �,.. bv- All Cape Environmental Services Inc. 7 Stratford Lane Yarmouth Port Ma. 02675 www.alicapeenvironmentalservice.com Operation & Maintenance Service Contract For SLUDGEHAMMER S-86 System „ This Contract is between Fancy's Market- Brian Smith hereafter referred to as "Owner") n y ( e ) and All Cape Environmental Inc. (hereafter'referred to as "ACE") for Operation & Maintenance of the treatment system listed below (hereafter referred to as the "System") System Owner; Fancy's Market; Brian Smith System Address; 699 Main Street, Osterville Ma. Permit Information; Management Level; Remedial Contact Information; 1. Maintenance and Other Services. ACE agrees to provide the following services to Owner during the Term of this Contract; (See attached Schedule C for additional & specific service requirements related to SLUDGEHAMMER S-86 system) 1,1,Inspection& Operation, ACE agrees to inspect and operate the system in accordance with Massachusetts DEP approval and manufactures requirements. Interval for inspections to be Quarterly 1,2,Maintenance&Service,ACE agrees to maintain system in accordance with Massachusetts DEP approval and manufactures requirements. Interval for maintenance to be Quarterly (to be combined with inspections) 1,3.Field Sampling,ACE agrees to field sample effluent samples for PH, Temperature, DO, and Turbidity. All meters to be in good working order and calibrated per manufactures requirements. 1.4.Laboratory rnfluent& Effluent Sampling,ACE agrees to pull influent & effluent samples for laboratory analysis from a Massachusetts Certified Laboratory, per DEP and Town Board of Health requirements No Influent sampling required, Bi- Annual Lab sampling BODS, &TSS 1,5,1nfluent Testing for;NONE REQUIRED 1 All Cape Environmental Services Inc. 7 Stratford Lane Yarmouth Port Ma. 02675 www.alicapeenvironmentalservice.com 1.6.Effiuent Testing for; Bods&Tss 1.7.Pumping of Ho/ding Tanks ACE agrees to check scum &sludge layers. ACE will recommend when to pump tanks. Please note that all grease traps are required to be pumped no less than quarterly. 1.8.Emergency Service Calls. ACE agrees to provide emergency service calls as provided in Section C 1.9.Warranty Service. ACE agrees to provide warranty service as provided by manufacturer and Section C 2. Payment for Services. Payment for services will be in accordance with Schedule D 3. Contract Term. The term for this contract shall start on September 1, 2010and continue on an annual basis, unless the contract is terminated early as provided in Schedule C. 4. Requirement for Service & Maintenance, Advise to Agencies. Owner acknowledges that Government agencies may require the following activity; 4.1. That the above referenced treatment system requires regular service and inspections. 4.2. That a copy of this contract will be made available to government agencies by ACE. 4.3. That ACE must advise the agencies if this contract is terminated at any time regardless of the reason S. Limits on Contract Services. Actual contract fee covers only the specific services as set forth in this Contract. Any additional services requested by Owner or required by regulatory agencies, including any additional testing services that are not specifically listed above and may be required by regulation or permit(s) to operate, will be provided at an additional cost. This Contract applies only to services relating to the treatment system itself and does not apply to any other parts of the building, wiring, or the like. 6. Care of the System by Owner or Tenant; Owner agrees to operate the system in a way consistent with DEP approval letter, Town Board of Health requirements, and Manufactures recommendations and instructions. 7. Other Parts of Contract. Attached and made part of this contract as if set forth in full here are the following; • Schedule A (describing unit location and regulatory requirements • Schedule B (operating conditions) • Schedule C (contains additional terms and conditions of this contract) • Schedule D (schedule of fees and payment terms) • Schedule E (addendums and or other terms/conditions) SCHEDULE A— DESCRIPTION OF TECHNOLOGY & REGULATORY REQUIREMENTS Make and Model;. Sludgehammer S-86 Serial No; State Permit # Town Permit # Management Level &Testing/Inspection information; to be operated under the remedial approval letter dated August 4, 2009 2 I All Cape Environmental Services Inc. 7 Stratford Lane Yarmouth Port Ma. 02675 www.allcapeenvironmentalservice.com SCHEDULE B — OPERATING CONDITIONS Owner acknowledges that the following items can overtax the biological process of the system and shall avoid introducing dental floss, disposable diapers, kitty litter, sanitary napkins, tampons, cigarette butts, condoms and other items of similar nature. Owner acknowledges that the following can destroy the biological process and agrees to not introduce chemicals such as paints, varnishes, thinners, waste oils, photographic solutions, pesticides and excessive amounts of household chemicals into the system. Other operating conditions; Sanitary Septage only SCHEDULE C — ADDITIONAL TERMS AND CONDITIONS OF CONTRACT This Schedule C is part of the attached Maintenance Contract between Owner and ACE. This Schedule contains additional terms and conditions of the Contract. C1. Inspections & Operation. ACE agrees to inspect and operate the system in accordance with Massachusetts DEP approval. Including: (1) Quarterly inspections and reports (2) Continuous operation by licensed and properly trained personnel (3) Sludge &Scum levels in all tanks with recommended pumping. (4) Visual and Field testing of effluent for PH, DO, Temperature, Turbidity, Color, and Smell (5) Meter readings for voltage and amperage on all electrical components that are part of the system. C2. Maintenance Services. ACE agrees to maintenance services as recommended by manufacture and DEP approval including; (1) Performing all recommended and required manufactures maintenance items Quarterly (to be combined with inspections) (2) Adjusting, cleaning and/or the replacement of any mechanical or electrical components of the treatment system that appear to require it. (3) Refilling, and or replacement of chemicals/bacteria bags that may be required by system. C3. Other Services and Charges. There will be a charge for any parts, repairs, or pumping except for covered warranty items and or items specifically listed above 3 All Cape Environmental Services Inc. 7 Stratford Lane Yarmouth Port Ma. 02675 www.alIcapeenvironmentalservice.com C4. Emergency Service Calls. ACE agrees to provide Emergency Service, calls for System in accordance with the following. C4,1 Availability, Emergency services will be available for response within 24 hrs. C4,2 Cost for Call, Emergency Service fees as provided in Schedule D may or may not apply depending on time and condition of emergency. C4,3 Cost ofParts, Labor, and or Pumping. Owner to pay for all parts, labor, and or pumping that may be required on the emergency call, except for parts and labor that may be covered under warrantee. C5. Warranty Service. ACE agrees to provide all services and secure replacement parts for the System to the extent covered by the Supplier's component warranty program, and ACE will communicate with the Supplier to secure the benefits of the warranty program for Owner when they apply. The Supplier makes all decisions on component warranty program coverage. Any dispute on warranty coverage, service or installation instructions, or parts will be between the Owner and the Supplier, and Owner shall not hold ACE liable in connection with any such dispute. C6. Dependence on Owner's Representations. Owner represents that he or she owns property listed in Schedule B is true and accurate. In entering into this Contract, ACE has relied on those representations and ACE representative's own observations. Owner understands that any inaccuracy of the information Schedule B or any future change in that information could void ACE's and Supplier's obligations under this Contract and could require replacement of the System and or other parts of the Septic System with equipment having a greater capacity, all at Owner's expense. C7. Access to Owner's Property. Owner agrees to provide ACE with access to the System and all other parts of the Septic System, as well as to the water and electrical systems at the property, at all reasonable times as may be needed for ACE to perform its obligations under this Contract and to perform such testing as may be required by regulatory agencies. C8. Extension of Contract.' This contract shall renew automatically provided Owner is current with all required payments and renewal fees are paid. C10. Early Termination. This Contract may be terminated prior to the end of its Term (including any extended Term) as follows: C10.1 by ACE, This Contract may be terminated by ACE: (a) if Owner defaults in making any payment called for by this Contract or in making any payment for services, repairs, or parts provided by ACE for the System, if the default continues for more than 30 days past the due date, or (b) if Owner defaults in performing any material obligation under this Contract (other than payment obligations) and the default continues for more than 30 days after ACE gives notice of the default to Owner. 4 All Cape Environmental Services Inc. 7 Stratford Lane Yarmouth Port Ma. 02675 www.aIIcapeenvironmentalservice.com C10.2byOwner. This Contract may be terminated by Owner: (a) if ACE defaults in performing any material obligation under this Contract and the default continues for more than 30 days after Owner gives notice of the default to ACE, (b) if Owner transfers the property, as contemplated by Section C15 below, (c) if the owner removes the system per all applicable laws and regulations,., or (d) if Owner replaces the System with a different system. C11. Effects of Termination. Upon termination of this Contract by early termination pursuant to Section C10 above or by expiration of its Term: (a) ACE will notify all applicable governmental agencies and Licensor of the termination (but that notice might not relieve Owner of any obligation of Owner to give similar notice) and (b) all obligations of Owner, ACE and Licensor under this Contract will cease, except that termination shall not relieve any party of any liabilities owed to the other that accrued prior to the termination. -C12. Payments. Fees and payments are covered under Schedule D C13. Defaults in Payments for Services, Etc. C13.1 Applicable to Contract Fees, Service Fees, and Parts The provisions of this Section C11 shall apply not only to the fees provided for in this Contract but also to all other amounts that may become owing by Owner to ACE for any services and for any parts that ACE may provide in connection with the System or the Septic System, C13.2 Late Payment Fee. Any payment made more than 30 days after it is due will incur a late payment charge equal to 2% of the amount due. The late payment charge will be due as soon as ACE sends Owner a bill that includes it. C13.3Interest. In addition, all amounts unpaid more than 30 days from the due date will incur an interest charge calculated at a rate equal to the lesser of 2% per month or the maximum rate allowed by applicable law. In such cases interest will accrue, on a daily basis using the above rate, from the 301" day of after the due date until the date of actual payment. C13.4 Collection Costs In addition, ACE shall be entitled to recover its actual and reasonable costs incurred in collecting any such overdue amounts, including reasonable attorney's fees and court costs. C14. Changes in Regulatory Requirements. ACE agrees that, if at any time any government agency changes the applicable requirements for inspection services or for inspectors relating to the System or the Septic System so as to increase the requirements applicable on the date of this Contract, then ACE will satisfy those increased requirements: In any case, ACE shall be entitled to increase its fees under this Contract by an amount equal to ACE's cost increase resulting from those increased requirements, plus 15%. ACE shall give Owner at least 60 days prior notice of any such fee increase. C15. Sale of Property. Owner may transfer the benefits of this Contract to any purchaser or other person who acquires the property where the System is located, provided all service fees and any other charges are paid when due. A $50.00 service fee may be required. 5 All Cape Environmental Services Inc. 7 Stratford Lane Yarmouth Port Ma. 02675 www.alicapeenvironmentalservice.com C16. Assignment by O&M Provider. ACE may assign its rights and obligations under this Contract to any 0&M Provider of the System who has been authorized by the Licensor to provide maintenance service, provided that the new service provider assumes ACE's obligations under this Contract. Without assigning its rights or obligations under this Contract, Licensor shall have the right to retain subcontractors or other agents to perform some or all of the services called for in this Contract. C17. Force Majeure. If Supplier, ACE or Owner is delayed or prevented from the performance of any act required . . under this Contract by reason of Act of God, strikes, lockouts, labor troubles, inability to procure materials (including energy), power, casualty, inclement weather, restrictive governmental laws, orders or regulations, riots, war or another reason of a. similar nature not the fault of the party delayed in performing the act required under this Contract, then the requirement for performance of the act shall be extended for a period equivalent to the period of such delay. This Section shall not, however, operate to excuse Owner from prompt payment of fees or other charges covered by this Contract. C18 Notice. Any notice or similar communication required to be given pursuant to this Contract shall be validly given if set forth in writing and if that writing is delivered personally or delivered via facsimile transmission to any phone number for such messages set forth in this Contract (with confirmation) or if the writing is sent by first class such other facsimile number or address for which notice of the change has been given to the other parry). C19 Miscellaneous (a) Law Applicable. This contract shall be governed and construed under the laws of the State of Massachusetts without regard to its principles of conflict of laws. (b) Amendment, Except as otherwise expressly provided herein, this Contract may not be amended except by written agreement signed by both parties. (c) Heading. The section headings in this Contract are for ease of reference and shall not affect the meaning of any of the provisions of this contract. (d) Inflation Index, Any increases in the cost of maintenance will occur at the Annual anniversary of the Agreement and be based upon the following: Increased labor costs not to exceed the National Consumer Price Index (CPI) percentage change (January to January of previous year), increases for equipment and parts not to exceed factory increases. SCHEDULE D— FEES AND PAYMENTS D1. Service & Inspection Fees. Annual service and inspection fees are due as invoiced and are calculated as follows; DZ.Z Inspections- Quarterly inspection at a rate of $150.00 per inspection 6 r i All Cape Environmental Services Inc. 7 Stratford Lane Yarmouth Port Ma. 02675 www.alIcapeenvironmentalservice.com D1,2 Maintenance&Service- Quarterly (to be combined with inspections) Service at a rate of$150.00 per event D2. Emergency Service Fees. Will be charged at the rate of $150.00 for the first hour then $125.00 per hour for the next 3 hours. After the first 4 hours the rate will drop to $90.00. Owner may request a quote for the repairs. D3. Unscheduled Repairs &Service Fees. Will be charged at the rate of $125.00 per hour for the first four hours then $90.00 per hour after that. Owner may request a quote for work to be done. D4. Laboratory testing Fees; Cost per Cost per Analysis test Analysis test BOD5 $ . 31.20 NH3 $ 27.04 TSS $ 19.47 Alkalinity $ 19.76 NO2 $ 27.04 TN $ 73.84 NO3 $ 27.04 CBOD $ 36.40 TKN $ 43.26 Fecal Coliform $ 37.44 Please note that testing fees are subject to change without notice, and pricing is outside of All Cape Environmental's control. Only Massachusetts certif ed laboratories can be used. D5. Defaults in Payments for Services, Etc. D5,1 Applicable to Contract Fees, Service Fees, and Parts The provisions of this Section shall apply not only to the fees provided for in this Contract but also to all other amounts that may become owing by Owner to ACE for any services and for any parts that ACE may provide in connection with the System. D5.2 Late Payment Fee, Any payment made more than 30 days after it is due will incur a late payment charge equal to 2% of the amount due. The late payment charge will be due as soon as ACE sends Owner a bill that includes it. D5,3Interest In addition, all amounts unpaid more than 30 days from the due date will incur an interest charge calculated at a rate equal to the lesser of 2% per month or the maximum rate allowed by applicable law. In such cases interest will accrue, on a daily basis using the above rate, from the 30th day of after the due date until the date of actual payment. 7 . I All Cape Environmental Services Inc. 7 Stratford Lane Yarmouth Port Ma. 02675 www.allcapeenvironmentalservice.com D5,4 Collection Costs In addition, ACE shall be entitled to recover its actual and reasonable costs incurred in collecting any such overdue amounts, including reasonable attorney's fees and court costs. SCHEDULE E —OTHER TERMS AND CONDITIONS NOT MENTIONED ABOVE; Services to include all filters and pumps. Data logger and field inspection via installed inspection reports MON 11 14-or-%lfo� P(AN i)aW *4A� aO A 0 TO 6e, �� VAS O� :�5 O M�n� �r�N CJLt,L{ C ONCU\c�S W A. W�, $�iN ` i`s THIS SERVICE CONTRACT WILL BE VALID AND BINDING WHEN OWNER AND O&M PROVIDER HAVE SIGNED IN THE APPROPRIATE PLACES BELOW. All Cape Environmental Inc. (Full Legal Name of Owner) (Full Legal Name of 0&M Provider) By: (Authorized Signature) (Authorized Signature) As: As: VP Sales & Service (Title of Person Signing) (Title of Person Signing) Date: Date: 8 ti y SLUDGEHAMMER ABG S-86 2 Year Monitoring Plan September 2010 thru September 2012 For the first month after installation: Weekly Inspections/Monitoring(minimum of 4 weeks) 1. Monitoring of SAS liquid levels by means of data logger with a minimum of 24 logging events'per day 2. Field sampling of effluent at inlet of pump chamber testing for PH, DO,Turbidity and Temperature 3. Field sampling of effluent at D-Box for PH, DO,Turbidity and Temperature 4. Inspection of Septic Tank for sludge and scum levels 5. Inspection of Grease Trap for depth of grease 6. Inspection of all filters 7. Inspection of ABG unit and compressor 8. Inspection of Pump Chamber sludge and scum levels 9. Water use readings 10. Pump run times and override events(making adjustments as required) At the end of 4 weeks a lab sample will be pulled testing for BODs and TSS along with field sampling for PH, DO, Turbidity, and Temperature. At the end of one month and successful operation of upgrade the above monitoring plan will move to a quarterly schedule with lab samples for Bods and TSS sampled at the D-Box. Quarterly schedule to remain in effect for the next two years,at which time owner may request reduction in monitoring/sampling from the Board of Health. Data Logger events to be reduced to a minimum of one daily logging of SAS levels. If during a quarterly inspection, system fails any of the field tests,weekly monitoring will be placed in effect and reason for failure corrected. Weekly monitoring to continue for a minimum of two weeks after passing field tests. Passing field tests are 1. DO-greater than 2 mg/I 2. PH—between 6&9SU 3. Turbidity—less than 40 NTU 4. No offensive odor All Inspections/maintenance to be entered into Barnstable County Health Department Carmody-data base Rev 19/13/10 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENERGY & ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 DEVAL L.PATRICK IAN A.BOWLES Governor Secretary TIMOTHY P.MURRAY LAURIE BURT Lieutenant Governor Commissioner • APPROVAL FOR REMEDIAL USE Pursuant to Title, 310 CMR 15.000 Name and Address of Applicant: SludgeHammer Group Ltd. 336 S. Division Road Petoskey, MI 49770 Trade name of technology: SludgeHammer ABG, model S-46 and S-86 (hereinafter called the "System"). Schematic drawing of a typical System and Technology checklist are attached and are a part of this Approval. Transmittal Number: X228133 Date of Issuance: August 4, 2009 Expiration date: August 4, 2014 Authority for Issuance Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000, the Department of Environmental Protection hereby issues this Approval for Remedial Use to: SludgeHammer Group Ltd , 336 S. Division Rd., Petoskey, MI 49770 (hereinafter"the Company"), approving the System described herein for Remedial Use in the Commonwealth of Massachusetts. Sale and use of the System are conditioned on compliance by the Company and the System owner with the terms and conditions set forth below. Any noncompliance with the terms or conditions of this Approval constitutes a violation of 310 CMR 15.000. • J August 4, 2009 Glenn Haas, Acting Assistant Commissioner Date Bureau of Resource Protection This information is available in alternate format.Call Donald M.Gomes,ADA Coordinator at 617-556-1057.TDD#1-866-539-7622 or 1-617-574-6868. MassDEP on the Worid Wide Web: http://www.mass.gov/dep �" Printed on Recycled Paper y t Renewal of Approval for Remedial Use Page 2 of 9 SludgeHammer System I. Purpose 1. The purpose of this Approval is to allow use of the System in Massachusetts, on a Remedial Use basis to repair systems failing to protect public health and safety and the environment where failure has occurred as described in 310 CMR 15.303 (1) (a) (1) and (2) due to clogging of the soil absorption system (SAS) and where the SAS is not being replaced. 2. With the necessary permits and approvals required by 310 CMR 15.000, this Approval for Remedial Use authorizes the use and installation of the System in Massachusetts. 3. The System may only be installed on facilities that meet the criteria of 310 CMR 15.284(2). 4. This Approval for Remedial Use authorizes the use of the System where the local approving authority finds that the System is for upgrade of a failed, failing or nonconforming system and the design flow for the facility is less than 2,000 gallons per day (GPD). 5. This approval is limited to the applicant's use of the technology. MassDEP makes no determination concerning any ownership interest or any other property or legal rights associated with the use of the technology. II. Design Standards 1. The System consists of an aeration device,40 watt unit operated on a continuous basis, and a System bacterial source installed in an existing septic tank or a new septic tank designed in accordance with 310 CMR 15.223 through 15.228. The bacterial source consists of plastic media coated with the bacteria. The'System converts the septic tank into a facultative bioreactor to treat residential strength wastewater from facilities with a design flow of less than 2,000 GPD. The treated effluent is discharged to the existing soil absorption system. 2. A microbial culture is established in the septic tank and maintained using the aeration device and the bacterial source. The aerator mixes the contents of the septic tank with the bacteria and aerates the liquid. The System's biomass reduces both the biochemical oxygen demand (BOD5) and the total suspended solids(TSS)concentration in the effluent from the septic tank. The effluent from the septic tank contains dissolved oxygen and System bacteria that discharge to the SAS and act to reduce the thickness of the biomat improving the soil absorption capacity. 3. Prior to installation of the System,the site shall be evaluated in accordance with 310 CMR 15.100 through 15.107. The existing on-site system including the septic tank,distribution box and SAS shall be inspected in accordance with 310 CMR 15.302. 4. The System shall not be proposed for installation where: Renewal of Approval for Remedial Use Page 3 of 9 SludgeHammer System A. The high groundwater elevation determined in accordance with 310 CMR 15.103 would be less than two feet with in soils with a recorded percolation rate more than two minutes per inch or less three feet in soils with a recorded percolation rate of two minutes per inch or less below the bottom of the SAS. B. A facility for which the site investigation indicates that the existing onsite system was designed and installed for a design flow smaller than required by 310 CMR 15.203. The minimum area for the existing SAS shall not be less than 50 percent of the area required in accordance with 310 CMR 15.242. C. An existing septic tank has not been tested and shown to be watertight. D. The proposed installation is for a failed or failing leaching pit or cesspool. E. A site investigation indicates that the existing soil absorption system must be removed and replaced. 5. The System shall be equipped with a monitoring device that provides data collection to include tracking the elevation of the effluent in the SAS, and temperature. The data can be stored and reported to include high, low and average levels for each parameter each month and daily values for the last thirty days. 6. For seasonal use,the System shall be reactivated by the addition of a fresh culture of bacteria at each start up. 7. System installation shall not include modifications, excavations, or any other changes to the existing SAS, with the exception of the work required in item5. III. General Conditions 1. All provisions of 310 CMR 15.000 are applicable to the use of this System, the System owner and the Company, except those that specifically have been varied by the terms of this Approval. 2. Any required operation and maintenance, monitoring and testing shall be performed in accordance with a Department approved plan. Any required sample analysis shall be conducted by an independent U.S.EPA or DEP approved testing laboratory, or a DEP approved independent university laboratory. It shall be a violation of this Approval to falsify any data collected pursuant to an approved testing plan, to omit any required data or to fail to submit any report required by such plan. 3. The facility served by the System and the System itself shall be open to inspection and sampling by the Department and the local approving authority at all reasonable times. 4. In accordance with applicable law, the Department and the local approving authority may require the System owner to cease operation of the system and/or to take any other action as it deems necessary to protect public health, safety, welfare and the environment. r- Renewal of Approval for Remedial Use Page 4 of 9 SludgeHammer System 5. The Department has not determined that the performance of the System will provide a level of protection to public health and safety and the environment that is at least equivalent to that of a sewer system. No System shall be installed, upgraded or expanded, if it is feasible to connect the facility to a sanitary sewer, unless as allowed by 310 CMR 15.004. When a sanitary sewer connection becomes feasible, the facility served by the System shall be connected to the sewer, within 60 days of such feasibility, and the System shall be abandoned in compliance with 310 CMR 15.354, unless a.later time is allowed, in writing, by the approving authority. 6. Design, installation and operation shall be in strict conformance with the Company's DEP approved plans and specifications, 310 CMR 15.000 and this Approval. IV. Conditions Applicable to the System Owner 1. The System is approved for the treatment and disposal of sanitary sewage only. Any wastes that are non-sanitary sewage generated or used at the facility served by the System shall not be introduced into the System and shall be lawfully disposed. 2. Any effluent samples shall be taken at a flowing discharge point, i.e. distribution box, pump chamber or other Department approved location downstream of the treatment unit. Any required influent sample shall be taken at a point that will provide a representative sample of the influent. The system designer, subject to written approval by the Department, shall determine influent sampling locations. 3. Operation and Maintenance Agreement: A. Throughout its life, the owner shall operate and maintain the System in accordance with the Company and designer's operation and maintenance requirements and this Approval. To ensure proper operation and maintenance (O&M), the owner shall enter into an O&M agreement. No O&M agreement shall be for less than one year. B. No System shall be used until an O&M agreement is submitted to the approving authority which: i. Provides for the contracting of a person or firm trained by the Company as provided in Section V (6) and competent in providing services consistent with the System's specifications,with the operation and maintenance requirements specified by the Company and the designer, and with any specified by the Department; ii. Contains procedures for notification to the Department and the local board of health within five days of.a System failure or alarm event and for corrective measures to be taken immediately; and iii. Provides the name of an operator; which must be a Massachusetts certified operator if one is required by 257 CMR 2.00, that will operate and monitor the System. The operator must inspect and monitor Systems at least every three months in accordance with the Department's policy and anytime there is an alarm event. This Department policy,Inspection and Sampling in Title 5 EA Renewal of Approval for Remedial Use Page 5 of 9 SludgeHammer System Single Family Home Remedial,andGeneral Use Treatment Systems with Design Flows Less than 2000 gallons/day can be viewed on the internet at http://mass.govldep/water/wastewater /iatechs. htm. 4. The System owner shall at all times have the System properly operated and maintained in accordance with this Approval, the designer's operation and maintenance requirements and the Company's approved procedures and sampling protocols. The System owner shall notify the Department and the local approving authority in writing within seven days of any cancellation, expiration or other change in the terms and/or conditions of their O&M agreement. 5. Prior to transferring any or all interest in the property served by the System, or any portion of the property, including any possessory interest,the System owner shall provide written notice of all conditions contained in this Approval to the transferee(s). Any and all instruments of transfer and any leases or rental agreements shall include as an exhibit attached thereto and made a part thereof a copy of this Approval for the System. The System owner shall send a copy of such written notification(s)to the Department and local approving authority within 10 days of such notice being given. , 6. The System owner shall have the System monitored quarterly for depth of ponding and dissolved oxygen(DO) levels in the SAS. Should the System exhibit excessive ponding levels after three months of operation(water surface elevation equal to or greater than the water surface elevation prior to installation of the System), at a minimum,the following parameters shall be monitored: pH, BOD5, TSS, depth of effluent and DO in the SAS and water use. Also see Section II, item 5 above. Monitoring shall continue for at least one year when at the written request of the System owner, the Department may reduce the monitoring and reporting requirements. If after 120 days of operation, the System is in failure, the System shall be removed in accordance with Section V (7). 7. By February 15th of each year for the previous year,the System owner shall submit to the local approving authority all data collected in accordance with item 6, above, including all Department Title 5 IA O&M checklists and System technology checklists completed during the previous calendar year by the System operator for each inspection performed. 8. Prior to the issuance of a Certificate of Compliance for the System,the System owner shall record and/or register in the appropriate Registry of Deeds and/or Land Registration Office, a Notice disclosing both the existence of the alternative septic system subject to this Approval on the property and the Department's approval of the System. If the property subject to the Notice is unregistered land, the Notice shall be marginally referenced on the owner's deed to the property. Within 30 days of recording and/or registering the Notice, the System owner shall submit the following to the Department and the local approving authority: (i) a certified Registry copy of the Notice bearing the book and page/instrument number and/or document number; and (ii) if the property is unregistered land, a Registry copy of the owner's deed to the property, bearing the marginal reference. Renewal of Approval for Remedial Use Page 6 of 9 SludgeHammer System V. Conditions Applicable to the Company 1. The Company shall develop and submit to the Department within 60 days of the effective date of this Approval: minimum site evaluation criteria and installation requirements; an operating manual, including information on substances that should not be discharged to the System; a technology inspection checklist; and a recommended schedule for maintenance and replacement of the plastic media essential to consistent successful performance of the installed Systems. The Company shall develop and submit to the Department within 60 days of the effective date of this Approval a standard protocol essential for consistent and accurate measurement of the performance of installed Systems, including procedures for sampling, collecting data and analysis of the System effluent and evaluating effluent depth in the SAS. The sampling and analysis protocol shall be in accordance with the latest edition of Standard Methods for the Examination of Water and Wastewater. The Company shall make available, in print and electronic format, the referenced procedures and protocol above to owners, operators, designers and installers of the System. The Company shall submit to the Department within 60 days of the effective date of this Approval a complete manual on operation of the SAS monitoring unit and the procedures required to conduct monitoring of the System and any procedures that will be implemented should the monitoring System fail. 2. By February 15th of each year, the Company shall submit a report to the Department, signed by a corporate officer, general partner or Company owner that contains information on the System, for the previous calendar year. The report shall include the following information: A. The total number of units of the System sold for use in Massachusetts during the previous year; the address of each installed System, the owner's name and address, the type of use (e.g. residential, commercial, institutional) and the design flow; B. Date when system was installed and started up; C. Tabulation of the sampling parameters and results with backup inspection and laboratory sheets; D. Statistical analysis of the sampling results including but not limited to average and mean values; status of the SAS including depth of effluent and change in depth over the operating year; E. Tabulation of systems that are in failure as described in 310 CMR 15.303 (1)(a)(1) or(2) due to excessive ponding of effluent in the SAS, reasons for non- compliance and any corrective action taken including but not limited to design, installation and/or operation or maintenance changes required to reach compliance; F. The inspection results recorded on a Department approved inspection form and a technology checklist. The forms must be completed by the System operator and submitted to the Department with the annual report. Renewal of Approval for Remedial Use Page 7 of 9 SLudgeHammer System G. A general summary of the results for the year, any recommended changes to the design, installation and/or operation and maintenance procedures and a schedule for implementing those changes; and H. Warranty issues both resolved and unresolved or an explanation of any warranty claims that have been received and their resolution. 3. The Company or its designee shall review the plans and site evaluation conducted for the System prior to the sale of any unit to ensure that the.proposed installation of the System is at a site consistent with this Approval and the System's capabilities. The Company shall certify in writing that the System plan and existing site conditions conform to the requirements of this Approval and any requirements of the Company and shall submit a copy of that certification to the local approving authority and the System owner. 4. Prior to the issuance of a Certificate of Compliance for the System, the Company shall submit to the local approving authority and the System owner a signed certification that the System has been installed in accordance with the Company's requirements, the approved plan and this Approval. This certification in no way changes the requirements of 310 CMR 15.021(3). 5. The Company or the Company's approved operation and maintenance contractor shall maintain a contract with the System owner that: A. Provides for operating and maintaining the System with an operator that has been r h mconsistentwith the m trained by the Company to operate the System Syste s specifications and any additional operation and maintenance requirements specified by the designer or by the Department; B. Contains procedures for notification to the System owner, the Department and the local approving authority within five days of knowledge of a System failure and for corrective measures to be taken immediately; C. Contains procedures for inspecting the plastic media bacterial source at each quarterly visit and if necessary replacing the media. At a minimum, the microbial inoculants shall be replaced annually; and D. Contains a plan to determine if required after the first three months of operation why the effluent water surface elevations in the SAS are as high or higher then the water surface elevation when the System was installed. 6. The Company shall institute and maintain a program of operator training and continuing education, as approved by the Department. The Company shall maintain and annually update, and make the list of qualified operators available by February 1st of each year. The company shall update the list of qualified operators and make the list known to users of the technology. a 7. The Company shall provide to each System owner a written warranty transferable to a new owner that includes the following: A. Refund of the cost of equipment and installation should the System continue in failure as described in 310 CMR 15.303(1)(a)(1) and (2) after 120 days of Renewal of Approval for Remedial Use Page 8 of 9 SludgeHammer System operation that is conducted in accordance with the Company's specifications and oversight; or B. Refund of the cost of equipment and installation should the System fail as described in 310 CMR 15.3 03(1)(a)(1) and (2) within two years of installation provided that the System owner has entered into and maintained an operation and maintenance contract with the Company and has operated the System in accordance with the Company's specifications. 8. The Company shall conduct a performance evaluation starting after the first 100 systems have been installed and operating for at least one year. A report shall be submitted to the Department no more than 180 days beyond the one year period evaluating whether at least 90 percent of the units installed for at least one year have demonstrated a reduction in depth(data as required in Sections II, item 5 and IV, item 7) and that the reduction in depth of the effluent elevation for the SAS systems has occurred within 120 days of start up or that ponding elevations are not excessive. Should the System not demonstrate the capability to reduce or eliminate ponding in 90 percent of the failed systems, the report shall detail the changes that must be made in site evaluation, design, installation and/or operation or maintenance to meet the goal and shall include a schedule containing a deadline for implementing those changes. No more than 100 systems shall be installed until the performance report has been completed and the results indicate that over 90 percent of the Systems are no longer in failure. 9. The Company shall include copies of this Approval and the procedures and protocol described in Section V (1) with each System that is sold. In any contract executed by the Company for distribution or re-sale of the System, the Company shall require the distributor or re-seller to provide each purchaser of the System with copies of this Approval and the procedures and protocol described in Section V (1). 10. The Company shall notify the Director of the Watershed Permitting Program at least 30 days in advance of the proposed transfer of ownership of the technology for which this Approval issued. Said notification shall include the name and address of the proposed new owner and a written agreement between the existing and proposed new owner containing a specific date for transfer of ownership, responsibility, coverage and liability between them. All provisions of this Approval applicable to the Company shall be applicable to successors and assigns of the Company, unless the Department determines otherwise. 11. The Company shall furnish the Department any information that the Department requests regarding the System within 21 days of the receipt of that request. 12. If the Company wishes to continue this Approval after its expiration date, the Company shall apply for and obtain a renewal of this Approval. The Company shall submit a renewal application at least 180 days before the expiration date of this Approval, unless written permission for a later date has been granted in writing by the Department. This approval shall continue in force until the Department has acted on the renewal application. 1 •L 1 Renewal of Approval for Remedial Use Page 9 of 9 SludgeHammer System VI. Reporting 1. All notices and documents required to be submitted to the Department by this Approval shall be submitted to: Director Wastewater Management Program Department of Environmental Protection One Winter Street- 5th floor Boston, Massachusetts 02108 VII. Rights of the Department 1. The Department may suspend, modify or revoke this Approval for cause, including, but not limited to, non-compliance with the terms of this Approval, non-payment of the annual compliance assurance fee, for obtaining the Approval by misrepresentation or failure to disclose fully all relevant facts or any change in or discovery of conditions that would constitute grounds for discontinuance of the Approval, or as necessary for the protection of public health, safety, welfare or the environment, and as authorized by applicable law. The Department reserves its rights to take any enforcement action authorized by law with respect to this Approval and/or the System against the owner, or operator of the System and/or the Company. VIII. Expiration Date 1. Notwithstanding the expiration date of this Approval, any System sold and installed prior to the expiration date of this Approval, and approved, installed and maintained in compliance with this Approval (as it may be modified) and 310 CMR 15.000, may remain in use unless the Department, the local approving authority, or a court requires the System to be modified or removed, or requires discharges to the System to cease. 08/16/2010 15:59 508-362-2425 ALL GAPE ENVIRONMENT PAGE 01/01 Fancy's Market Petersons Market 699 Main Street 918 Main Street Osterville, MA 02655 Yarmouth.Port,MA 02675 Phone: (508)428-6954 Phone: (508)362.2147 Fax: (508) 420=0863 , Pax: (508) 375.0509 ��SS •Y To: Winston Steadman Date: 8/2/2010 From: Brian Smith RE: Permission to install Sludgehammer System Winston, I have read through the material on the proposed sludgehammer install. I firmly believe that your plan provides a comprehensive approach that will include the install, continued operation and maintenance of the entire system. Please start the process of filing with the town., and the board of health. Thank You Brian F. Smith Pirana O&M System Check List installed Residence of=> Authorized Service Provider Location Inspected by Address Phone Number e-mail GPS Lat&Lon System ID date Signature Phone Number Contract Status/Expiration E-mail Field Monitoring System Inspection System ID _.. . -. . Data log last report Current time if not flashing or today's time Level Inches above sensor at time of inspection Low Average Hourly Level In last 24 hours Temperature Now if not flashing or last record Last Download Toda 's time and date Aeration System Air pressure sensor/and light OK Aeration Pattern Check One and Comment Fine even pattern Coarse large bubbles Low Volume fine bubbles Less than normal - 1-12S Odor No air- septic odor conditions Odor Clean Pirana Odor Aerobic 1-12S Odor Septic Odor Microbial Generator Good Healthy Tan Population Appearance _ Gray color bag Black bag Picture taken foranalysis Black No bacteria on bag or stick Nitrate level mg/I Micro Replacement IID Number r s :" VM t r x s Outlet�iBaffle or Filter.;�,f� ,�x, ��. ,3 Water level in tank normal Outlet flushed/cleaned D,:Box Condition ;if'accessible _..d Clean and free draining Even flow split Flow split adjusted how? Other Field Conditions Trench or Pit 1 depth in inches Trench or Pit 2 depth in inches Trench or Pit 3 depth in inches Landsca e Draina e Roof diverted Driveway runoff diverted Other drainage in yard (swales OK) r'' LEGEND N 97.24 x EXISTING SPOT GRADE ° o ' ' EXISTING CONTOUR °' ' \ Oak o 96 PROPOSED CONTOUR � Ln —W— EXISTING WATER SERVICE —G— EXISTING GAS SERVICE O �63 /� — 913 � �' = a O.H.W.— EXISTING OVERHEAD WIRES 9 ^� ly o +5 EXISTING WATER SHUT—OFF fir\ Q• �31 r \ a Main St s p w [p EXISTING GAS SHUT—OFF 9� TEST PIT m o BENCHMARK 1 ! ,16 9?—� I \y, R'Onno 3 Av LOCUS Rd e !BLIDG' oea q�F�/i " i LOCUS MAP #707j �Q/ V7 I'� o \ / �!y NOT TO SCALE APN 141-012 � I \\ � yb<.;ali I � Illll � l �s� �?c 891 .�° ��4.�8 SAW—CUT PAVEMENT AND INSTALL 5 INSPECTION PORTS. MANIFOLD ALL I ce` T�S,O / l 11 { I 1 0 Pam INSPECTION PORTS AND CONNECT TO t g p o I I EXISMV { f 90) PROPOSED VENT (VENT-2). BUILDING (#699)' I I I S I TOF=95.10 /9�S i O.H.W. j 98& o �� LOT A " - .2 NOTES: 7,4Z: S.F. 1 ! 1) OWNER HAS REQUESTED TO WITHDRAW FROM THE I O SITE SPECIFIC PILOTING PERMIT BY DISCONNECTING 9, li APN 141-011 ! , , � 11 ( THE SOILAIR UNIT. BLDG. 9g 0k �e � T WATER METER MH j 46 3� � I I I ( I I 4 � ! i I � 2) OWNER WISHES TO INSTALL A SLUDGEHAMMER 5-86 1 i#7051 /\Ai / .1 I FLOOR EL=90.34 I f I I I I © UNDER THE GENERAL APPROVAL. . 1 O j•68� 6RAw RIM EL.=90.15 I 3) ADDITIONAL SEPTIC SYSTEM MODIFICATIONS INCLUDE VENT I ABUTT. SMH/ / �0 (I I - 1 ENHANCEMENT, NEW PUMP WITH TIMED DOSING AND _ \ °fie I i I I 1 I ; E INSTALLATION OF MORE AGGRESSIVE EFFLUENT FILTERS 90 p6 Cr �,P 0 i IN THE GREASE TRAP, SEPTIC TANK AND PUMP. ale /as 0� / ( ��/L'i qj C�9 I ' 1 6y , `14 \ / PARK�G ANT 1? /95.49 Qo 9 S EX1STlNG DRY WELL I 1 1, � \' EXISTING SEPTIC TANK /�-�,,,� ADD ZABEL FILTER (MODEL NO. A1800) EXISTING GREASE TRAP ADD ZABEL FILTER (MODEL NO. A600) Co '7 �e°` /J° BENCHMARK NO.1 CTR. MH 0 `(IP° e / ELEV:092.131NLET(ASSUMED) PROPOSED SLUDGEHAMMER INSTALLATION 98>S \ aC> ep9° ten 699 MAIN STREET OSTERVILLE MA NT— 5too" moo, I Yq�e oI PROPOSED PUMP CHAMBER � � / ° RIMS, EL.=92.8t - Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 0 INV.(IN)=86.08 a Z OWNER OF RECORD Engineering ey: Surveying by: SCALE DRAWN JOB. NO. UPi274A 9g / ABUTTING EXISTING S.A.S. THE 699 MAIN SREET, LLC Engineering Works WARNER SURVEYING 1-=20' P•T•M• 182-10 &3 0g PARKING 4 ROWS OF 6 — 16' HIGH CAP.(H20) BIODIFFUSERS c/o BRIAN SMITH 12 weal Cr fWd Rood 22 long Road I'Oi�F 1 ROW OF 5 — 16' HIGH CAP.(H20) SIODIFFUSERS 699 MAIN STREET Foreeidde,MA 02644 Harwich,L1n 02645 DATE NO. OSTERVILLE, MA 02655 (508)477-5313 (508) 432-8309 7/27/10 P.T.M. 1 Of 2 DESIGN CRITERIA EXTEND 8 VE 0' BUILDING USAGE (310 CMR 15,203): ABOVE VENT-2 1ST FLOOR - SUPERMARKET 3300 SF x 97 GPD/1000 SF = 320.1 GPD 2ND FLOOR - OFFICE - 1180 SF x 75 GPD/1000 SF = 88.5 GPD AIR PUMP IN ADD VENT-2 3RD FLOOR - OFFICE - 865 SF x 75 GPD/1000 SF = 64.9 GPD WATERTIGHT BASIN SET 2' ABOVE GRADE' TOTAL FLOW = 473.5 GPD ACTUAL WATER USAGE: 110 VAC - EXISTING EXISTING EACH VENT SHALL BE 2005 - 145,DO0 GALLONS - AVERAGE DAILY FLOW = 397 GPD EXISTING EXISTING CONNECTED TO ALL 2006 - UNRELIABLE DUE TO LEAK IN WATER SERVICE (REPAIRED) DISTRIBUTION LINES 2007 - 169,000 GALLONS - AVERAGE DAILY FLOW = 463 GPD INSPE ION PORTS DAILY FLOW: 463 GPD 2-SCH 40 PVC ~ 6' DESIGN FLOW: 474 GPD s 11.3' TO DESIGN FLOW PROVIDED: 0.74 x 862.8 = 638.5 GPD N VERT ws7ALL / EXISTING EXISTING EFFLUENrJ EXISTING 4 ROWS OF 6 UNITS AT 6.33'/UNIT = 38.0. FlLTER EXISTING D-BOX AND 1 ROW OF 5 UNITS AT 6.33'/UNIT = 31 J' (7Asct oR coua^ EXISTING EXISTING EXISTING - 5 OUTLETS (MIN.) EXISffNG SOIL ABSORPTION SYSTEM (PROFILE) SludggeHommer• Model S-86 to be IXISTING PUMP CHAMBER 'nstolled as shown on Schematic for CHANGE OUT PUMP RESTORED PAVED PARKING&BRICK WALKS General Use Approval 12'OF COMPACTED GRAVEL • Manufacturer: SludgeHammer Group Ltd. nRENCO HIGH-HEAD Em LI ENT POMP BACKnLL WITH CLEAN NATIVE SAND 336 South Division Rd. EASY PACK AS PROVIDED BY Petosky, MI 49770 ALL CAPE ENVIRONMENTAL aRENco CONTROL PANEL ," BIAXIAL GEOGRID/B%1100 MODEL No.MW-51 PT Ro TYPE PRODUCED BY TENSAR EXISTING SEPTIC TANK ANCHOR saENTlnC FLOATS CORP., ATLANTA, GA DOSING & STORAGE REQUIREMENTS (ADD ZABEL FILTER, MODEL NO. Al00) MODEL NO,SM15N0V. 6, EXISTING GREASE TRAP II -I�nlll�l DESIGN FLOW: 474 GPD ADD ZEXIS FILTER, MODEL NO. A600 2 8� DOSING: PUMP SHALL SET TO RUN AT ONE HOUR INTERVALS OVER ( ) OVER THE COURSE OF THE DAY. EFFECTIVE WIDTH=14.0' PROPOSED FLOATS SHALL BE: EXISTING SUITABLE 1) PUMP OFF MATERIAL 2) TIMER ON/OFF (4 ROWS OF 6) + (1 ROW OF 5) = 5 ROWS (29 UNITS) 3) TIMER OVERRIDE WITH NO SEPARATION BETWEEN EACH ROW & NO STONE 4) HIGH LEVEL ALARM (SET AT 24") XI (TNG SOIL ABSORPTION SYSTEM (SECTION) STORAGE PROVIDED: 2.25' BETWEEN INV.(IN) AND HIGH LEVEL ALARM STORAGE PROVIDED = 2.25' X 250 GAL/FT = 562.5 GALLONS SEPTIC SYSTEM PROFILE N.T.S PROPOSED SLUDGEHAMMER INSTALLATION 699 MAIN STREET, OSTERVILLE, MA Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 Engineering by: surveying by: SCALE DRAWN JOB. NO. Engineering Works WARNER SURVEYING NTS P.T.M. 182-10 12 West Crassfield Road 22 Long Road DATE CHECKED SHEET N0. Forestdole,MA 02644 Norwich,MA 02645 (508)477-5313 (508)432-8309 7/27/10 P.T.M. 2 Of 3 is SludgeHammer 4 a.,I u,,, bile . m a nf ed", The latest advance in v • Home • Pplicatioils • Products • News • Case Studies • Dealers • Comi)an • Contact type here to search Search How it works Septic systems fail. And the reason they fail is the soil in the disposal field clogs up with slime from the anaerobic (unoxygenated)bacteria that were once in your digestive system. The very protective coating that allows this bacteria to do its job in your gut ultimately ruins the typical septic system.. Until SludgeHammer, you had only two very costly options—you could repair or replace your system. The SludgeHammer is built to give you a third, and better, option. Waste and unoxygenated bacteria are the primary reason for failure of traditional septic systems. When large colonies of these anaerobic bacteria migrate from the septic tank to the disposal field they produce a mucus-like layer of slime, or biomat, which clogs the pores of the soil so air cannot circulate. Additionally, as they grow, this anaerobic bacteria creates large amounts of nitrate, a toxic element when produced in large quantities, which can, over time, seep into the local water table. The usual solution at this point is to pump the waste and clogs from the septic tank and start a new disposal field--costly solutions to a now avoidable situation. Air porn 110VAC Air fine in,basin A Service riser i ...... Effluent filter .............. inlet N: Outlet Aerobic Bacteria Vigorous Generationi Circula'110" System ............. The SludgeHammer Answer SludgeHammer provides an integrated two part response to the problem of long-term wastewater management.Oxygen is lethal to the anaerobic bacteria that inhabit septic systems. Simply and affordably,the SludgeHammer system can be installed into any existing septic system,aerating and circulating the effluent within the septic tank killing off all of the anaerobic bacteria. This introduction of oxygen creates the perfect environment for the SludgeHammer proprietary blend bacteria. The SludgeHammer matrix itself, with 150 square feet of surface area for the bacteria to grow and form colonies on, is placed in the inlet chamber. Liquid in the tank circulates through the unit, over the aerated bacterial colony, at a rate of 15,000-20,000 gallons per day, ensuring that every drop of liquid is processed up to 20 times a day. In this set up, the voracious SludgeHammer blend bacteria consume and digest the organic waste. The SludgeHammer microbes are so efficient that they turn effluent into clear water before it heads to the disposal fields, making clogs nearly impossible, and all this without producing the biomat slime that ruins septic systems. The SludgeHammer bacteria then proceed with the clear effluent into the disposal field where they digest the biomat slime and reopen the soil pores. Even though there is no air mechanically circulated to the disposal field the SludgeHammer microbes still thrive. Instead of directly absorbing oxygen the microbes strip nitrite of oxygen before it is turned into the more toxic form of nitrate, creating nitrogen gas through the process. Nitrogen, an abundant element within the atmosphere can now circulate out of the soil. As the SludgeHammer microbes digest the biomat the disposal field is revitalized and can once again accept and process the clear effluent coming from the SludgeHammer inoculated septic tank. The SludgeHammer microbes leave no resources for anaerobic bacteria to grow so they are defeated through competitive exclusion. The SludgeHammer microbes do not pose a threat to septic tank and disposal field clogs, because they break down organic matter and do not create the biomat slime produced by anaerobic intestinal bacteria. The bacteria will maintain a colony indefinitely as long as they are provided oxygen and waste, meaning a permanent solution to wastewater clogging and disposal problems. SludgeHammer Adaptability The SludgeHammer system is a living system. It grows as it has resources and decreases when resources are limited,meaning that it can customize itself to meet any needs. SludgeHammer has proven its adaptability and efficiency at unclogging and revitalizing failed septic systems.The same SludgeHammer system has also been adapted for marine and other uses,where the same basic technology breaks down organic matter into clear water which can then either be reintroduced into the local water table or repurposed for irrigation. Certifications Y ¢ i Testimonials The SludgeHammff technology was installed in May of 2003, and it is still going strongP There is no gooey crust. I doubt we will ever need to pump the tanks again. The sediment is gone. S U IN • x�e� &'Wavevn in Product Oraina9e A DMe . ZABEL Filters &4Uzsierrater Products A Doision W Po1y1ok In. i Y l r, OutdoorSmart Filter Alarm All Pol lok/Zabel f filters accept the % s SmartFilter® ' switch and alarm. s A100 Filter 1/16" Filtration A300 Filter 1/32" Filtration A600 Filter 1/64" Filtration 8" and 12" Diameter 8"and 12" Diameter 8"and 12" Diameter This filter is ideal for larger The finer 1/32" level of fil- The A600 is ideal for spe- homes,multi-family homes tration achieved with the cialty applications where or lightcommercial settings A300-8 filter makes this the very fine filtration is where increased flows or perfect effluent filter for required and low flows higher quality effluent small grease trap applica- are expected. Due to fine, is required. The A100-8 tions, dog kennels, laun- 1/64" level filtration, every Series is sized to handle dromats and other appli- A600 comes equipped with flow rates from 1200 to cations where fine sus- a SmartFilter® switch and 2400 GPD and is available in pended solids are present. alarm. The SmartFilter® three different lengths. The The A300 offers flow rates switch provides notification A100-12 Series, installed in between 1200-2400GPD. of required filter servicing more locations than any The A300-12 Series pro- through the use of both an other filter on the market, vides 1/32" filtration and audible and visual alarm. is sized to handle flow has been shown to reduce A minimum of a 3" drop rates from 3000 to 6000 FOG by as much as 50- is required in the tank for GPD. The A100-12 Series 98%. The A300-12 is also proper SmartFilter®opera- can be used in almost any used for onsite wastewater tion. The A600-8 Series application. Independent systems which require a filter is available in 18", 26" research has shown the finer level of TSS removal, and 32" lengths. The A600- A100-12 decreases TSS by The A300-8 Series filter is 12 Series is available in 50-90% and CBOD5 by 20- available in 12", 26" and 20", 28" and 36" lengths. 40%. With 1/16" filtration, 32" lengths. The A300-12 the A100-8 Series filter is Series filter is available in available in 18", 26" and 20", 28" and 36" lengths. 32" lengths. The A100-12 Series filter is available in 20", 28" and 36" lengths. www.polylok.com 1-877-765-9 8a v ` c ZABEL 12" CASES = Q 6.6J 663 �. 0�� 04,52 00- 27.75 19.60 15.29 2350 AIOOA69012N10CASE :�-=l . I J 0 A106AW012X26 C'A6E 31.25 J.46 a. 1 O Q MA8AIWA60012X36C41iO4 12"FILTER CASE SERIES MATERIAL65 12X20 CASE: HOUSING-POLYPROPYLENE BUSHING PVC 12X28 AND 12X36 CASES-ASS COLOR-GREY ZABEL 12"' FILTER SERIES A100(34PLATEB)31.1" h100(17 PLATES)15.67- Al D)126 PLATES A300(35PIATES)37.08' h300118 PLATES)16.03- A300(27 P LATE S)24.23- A600(36 PLATE ES A-3o0118 PLATES)15.75' ABDO(27 PLATES)23.87 e B B Ago e B B B e Al DD-A60012X20 CARTRIDGE 12'FILTER CARTRIDGE SERIES MATERIAL:ABS A100-A60012X28 CARTRIDGE COLOR: A-100-WHITE Mp OCKET ACCEPTS A-300-GREENILTER SWITCH A-600-BLACK ART NO,3D143aA-1DD-VIT FILTRATION 12x2D-138.50 FT. A700 A60012X36 CARTRIDGE 12X28.211.90 FT12x36.211.10FT. OA-300.182"FILTRATION:12X20.146.71 FT. 10 12X"220.05FT. 12X36-265.25 FT. AFOD-VW FILTRATION: FILTER PLATE 12X20-146.70 FT. 8.15 FT.OF FILTRATION 72X28.220.05 FT. PER FILTER PLATE 12X36.293.40 FT. www.polylok.com 1-877-765-9565 J Biotubee PackageEasYPak- Pump Applications Standard Features &Benefits Orenco's Biotube EasyPak' Pump Package is the first pump package • A complete system • Demand dosing and designed specifically for use in pump tanks to filter and pump effluent to in one box timed dosing sys- dispersal.* It includes the following components: • Drops right into a tems available • EasyPak' pump vault pump tank • Easy to select, • 4-inch turbine effluent pump • All parts designed install,and maintain • Biotube®filter cartridges (3) to work together • To order your free• Flow inducer • Vault keeps out EasyPak Design • Float switches with slidingcollars sludge,but allows Aid CD-ROM,call ars pumping to nearly 0renco at 800-348- • Discharge plumbing assembly the bottom of the 9843.Or you can • Splice box tank to meet large download every- • Control panel (demand dosing or timed dosing) reserve capacity thing on the CD by visiting the home The kit saves time for the installer and protects the drainfield from clog- requirementspage of orenco.com ging. Choose a system for demand dosing (to a Gravity drainfield) or Turbine pump lasts and clicking timed dosing(to a pressurized drainfield or mound). four times longer "New Products" *Patentpending than centrifugal or the EasyPak pumps and is war- graphic. rantied for five years • Turbine pump with stands the frequent starts and stops that timed dosing requires " Patented Biotube° filter has 14 ft2 of filter area N Snap-in float stem and adjustable float I y collars keep floats ,• securely itio e rel in os n, 'r til f speeding installa- tion and servicing �u N Built of molded The Eas PakT Pum y p m ��' � ABS and PVC for Package replaces _� � .".", long life pump-on-a- oc " ..� systems with a complete . package that's easy to - -- install and maintain. Combining components for filtration,pumping, and comrol, the EasyPak"Pump Package installs quickly in any pump tank(purchased separately)and allows pump- ing to nearly the bottom of the tank. Orenco Systems® Incorporated Changing the Way the APS-PTV-1 World Doer Wastewater` Rev.1.2,©05/09 1.800-348-9843 Orenco Systems®,Inc. www.orenco.com I► _ — _ j Biotube° EasyPak .. Components m Float tree Float tree bracket , Flow inducer ' Discharge plumbing r assembly Control panel Biotuoe®filter (Cold-weather and •Demand-dosing systems: cartridges(3) drainback discharge Simplex electro- assemblies also mechanical panel available) •Timed dosing systems: R Choice of analog or ,k digital timer panel a 4-in.turbine effluent pump r (10,30,or 50 gpm) Splice box' s An ate. i e g y� w EasyPak'vault Float switches with collars • Demand-dosing systems: high-level and on/off • Timed-dosing systems: high-level,timer off, External splice box also available and redundant off Model Code for Ordering To Order BEp u u u Call your nearest Orenco Systems®, Inc. distributor. For nearest distributor, call Orenco at (800) 348-9843, or I Discharge assembly: go to orenco.com and click on "Distributor Locator." Blank =Standard DB =Drainback CW =Cold weather Distributed By: Panel: DD = Demand dosing TDA = Timed dosing,analog TDD = Timed dosing,digital Pump flow rate(nominal): 10= 10 gpm(0.6 Usec)with 1/a-in.(6-mm)flow control 30=30 gpm(1.9 Usec) 50= 50 gpm(3.2 Usec) Biotube EasyPak`pump vault,15-inch(380-mm)vault No. Fee O� THE COIVIMONWEALTH� AS C US TS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for Tigpogal 6p!gtemc Conttruction Permit Application for a Permit to Construct( ) Repair(R)",Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components i Location Addressor Lot No. q rJ Owner's Name,address,and Tel No. er"� 51� L �+'vI �Le- � '� GgCi Mrs�,.� �1�. �� v;lUe,� Assessor's Map/Parcel 14( Cr bg - 4 9 8— O s 6r Installer's Name,Address,and Tel.No. R 01 CAPS EtJVift0AWJ0 LDesigner's Name,Address and Tel.No. W N N 40 a 41 -66A-a Mao 'C fli e f),o 4AA-0- i r-15- W L-C V. s o02 C CI S S ;(at Pn, fox 23 'S P0fl w4-, For_St-,DAie_ wry, 6AA Goal 5313 Type of Building:Dwelling No.of Bedrooms Lot Size 71 4-S b sq. ft. Garbage Grinder ( ) Other Type of Building MPNr'u-0-3r_/OC k No.of Persons Showers( ) Cafeteria( ) Other Fixtures /� C Design Flow(min.required) 474 rr gpd Design flow provided t7 3 U p 1 J gpd Plan Date f a I- -01 o Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. oX Description of Soil Nature of Repairs or Alterations(Answer when applicable) Ehngr& tq ►�i P' ®� ��i — CO I�AQS¢t,� T r� s S iN b�.a 1� rle� �,� �:,r-S ►�►c .se z'N 6?on? t9 rT S cro m Date last inspected: 14 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the E vironmental Code and not to place the system in operation until a Certificate of Co plianle has been issued by this rd of H th e Signe Date 01"') ao it) I Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued4_14, THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the Off-sit, site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by at 4; mayo has been construe cco dance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer 1/1 Designer #bedrooms Approved i n flow ZY' gpd The issuance of this permits 11 not Pe construed as a guarantee that the sys in w Il s signed. - Date f �� Inspector T r 36 No. 7�r C Fee O t "'""'°"�"ONWEALT Entered in computer: THE COMMH AS MUS TS Fy� PUBLIC HEALTH DIVISION.- -fQWN F BARNSTABLE, MASSACHUSETTS Yes i Application for ;Digpogal`*n!5tem Con.5truction Permit :r Application for a Permit to Construct( ) Repair(;<Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Addressor Lot No. Owner's Name,Address,and Tel.No. "gr'�' Sh,�i 4 Pon Assessor's Map/Parcel (b? - 4 A?_ 6 j s q Installer's Name,Address,and Tel.No. A\\ CAQe. Sf4V i aM 1 Designer's Name,Address and Tel.No. E µL I W,,nlh�nt R. 56acto,*ty 71T rIJT,,oVAW-- i,-, t"nrtt s t� C/vSS�t��G( Sr gyp. (�O'X a 3 5 `IAr-,n-.a P 0 r T . KX Fore-St'rDA ip- wry , '6 77' 5313 Type of Building: Dwelling No. of Bedrooms Lot Size 71 4 t fc:, sq. ft. Garbage Grinder ( ) Other Type of Building I ^CV-CT10(6i' � No.of Persons Showers(" ) Cafeteria Other Fixtures Design Flow min.re uv a /q� C g ( q d) ��i gpd Design flow provided �3 19, J gpd Plan Date1 p Number of sheets , Revision Date Title Size of Septic Tank QO Type of S.A.S. �JOX 'A 1� �� CP P ��o d _ r Description of Soil Nature of Repairs or Alterations(Answer when applicable) EtAer,�W5;4 l<si r OF S 'IN �1 T A c i s 1 ► ccl^ PI9 T icrom Date last inspected: i 4 Agreement: / "* The undersigned agrees to ensure the construction and maintenance of the afore described on"site sewage disposal:system in accordance with the provisions of Title 5-of the Environmental Code and not to place the system in operation until a Certificate of Complian'e has been issued by this ��ard of H th Signed,/��Y'4 '""!, � Date Application Approved by (/� O Y V Date Application Disapproved b PP PP y: '"" Date for the following reasons f Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the 0 'site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( -),by �� all) V at v f7'l om, s -I/� �S1P has been constructed ' ccordance with the provisions of Title 5 and the the for Disposal System Construction Permit No. 0— dated Installer A9 / raw Designer / LC #bedrooms Approved esZgn flow / gpd The issuance of this permit shall not Pe construed as a guarantee that the sys em w• 1 as designed. Date % � Inspector ector No. rk Fee " 7�rHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wt5pogal *pgtem Con$tructton Permit Permission is hereby granted to C ,nstruct�( ) Re air ( Upgrade ) Aban on System located at �/ � �, wl and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be c mpleted within three years of the date of this ermi Date Approved by No.2s----9i F�$..3C?... .a.. THE COMMONWEALTH OF MASSACHUSETTS o I BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Bi_npwial Worlw Toutitrnr#inn rantit Application is hereby made for a Permit to Construct ( ) or Repair ( &,<an Individual Sewage Disposal System at: .......0 lcl....�a.c: -----Sr------------------------------------------- ------0.S�c��cv j...�----------------------------------------------------- E. - oe'k )f _ dress' I— ...................... i t Y Pr I of No. -----^-----......------------------------------............------......... ------------------------------------------------------------------------.......................... r Owner - Address v _� f e..................e ...5----------------------------------- -----0 s t� , !!---..............�a ,.� Installer Address Type of Building Size Lot............................Sq. feet ►� Dwelling—No. of Bedrooms............. ----------_.._--Expansion Attic ( ) Garbage Grinder ( ) 1 a Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures _-------------------- --------------------------------------------------------------- ------------------------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------.-.-.gallons Length---------------- Width--------------.- Diameter--...---........ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-----....---........ Total leaching area....................sq. ft. Seepage Pit No--------__-_-.--- Diameter.................... Depth below inlet--------..---------. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- ------------------------------------------------------------------ Date........................................ W ,.a Test Pit. No. I..----_--------minutes per inch Depth of Test Pit-------------------- Depth to ground water.--...-----.........--.. GL, Test Pit No. 2................minutes per inch Depth of Test Pit--.........-----.--. Depth to ground water..............:......... a ---------------------------------------------------------------------------------------------------------------------- ------------------------ -..... -........ 0 Description of Soil----------------------------------------------------------------------------------------------------------------------------------------------------------------------- W U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.-------.-�41J-----.5ra -------- l..q.......34 ......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia%44U.7 a been issued by the board of health. S' ned -..... -.......... v- ' / Application,Approved By ---------- -------�- ---- ., .. .................... -------------------------.---------- � - `�_-- to Application Disapproved for the following reasons- ------------------- ------------------------------------------------------------------------------------------------------------ ----------------------------------- ---------------------------------------------- ------------------------------------------------------------------------------------------------------ ------ --------------------------------------- aDare Permit No. 1 J -'--- a ------------------ Issued ......--......., y �l'�� ----------- Date T •-r-.�f }�. --ter. mot/ Oil t �Y No. Ili ...0...�.a.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratioit for Di!ipwml Wor1w Tomitrnrtion ravAd Application is hereby made for a Permit to Construct ( ) or Repair ( ✓�an Individual Sewage Disposal System at: .......�� .C .c-�-?---•----------------------------------------------------- ------0 1�5. E- oc ,n-A _t. I 1 or lot No. --.......--•--•........................... : ................................................. -•---------•--------•---••----------------•----------•--------•---................................ Owner Address (.t)CL/ 2 i L e r v-` 5 0 si'e �� l I yoZ. 1 .._... e- Address ........a '7 V.�.. Iustaller Type of Building Size Lot............................Sq. feet era Dwelling— No. of Bedrooms______________ ---_---___---_.--Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria a ( ) F d Other fixtures --------------------------------•-•----------..--------------------------------------- -----------------------------------------•--------•---------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length-------- ------ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------- ---------- Diameter----.--.---------.-- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit. No. I------__-__-.-minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.-.-----------_--.-.-. Lr. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 9 ...............................•-•-••-...........................-----•--------------------------•-•.............. •-•--------•------------------------------- 0 Description of Soil........................................................................................................................................................................ V .-------------------- ------------------------------------------------------•----------------.......---------•----------------------•----------------------------------------------•-•------•------••---- W U Nature of Repairs or Alterations—Answer when applicable..-------- Tr e_____._.fr-.7'.� ......................... Y ..----...--•-••----------------•----------••---...•-------...------••••---••••--•-----------------•.•-•----••--•--•------------------------•--•-•------•-•••------•-•-•----•-••••-•-----........--•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issued by the board of health. - f . Si. ned ° .:.Dace..`...�-.-: Application Approved B c� — PP Pp Y ..,......._ . -------------------- --- — e` Application Disapproved for the following reasonr: ------------------------------------------------- --------:.,..........--------------------------------------................... t i Dne Permit No. --------C -------------------- Issued ................. 32 -' ' ............. Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gex#tftra e of Tomplialnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( L-- ) by .......... L..e.w..t...-5.....----------------------_...--------------------- --------------------------------------------- Instau_r at ....... .......... 7�.. ._......a-s..f e-`-'J--'--�---- -�- ---------------------------------------------------------------------- --- _ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the 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....- � � '-.G.. 7----_ ---------------------- Inspector --...------ - , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......... FEE........................4 Uiopoottl Works Tonntrir#ion "an it Permission is hereby granted........ t ........ ---------------------------------- .......................................... to Construct ( ) or Repair (V<an Individual rSewage Disposal System --••-•- •-('G`--'--"------S--�--=----- 2.s..�"��'-��''--'-- --/--'--------------------------------------------------------------_------------.-. at No.----�---�--� Street qq q �� as shown on the application for Disposal Works Construction Permit No.f�` (_-__ Dated........ ..-_�-�"-/...�...•.... �g / Board of Health DATE................... - ..- LJ ............................ FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS 1 pig� u. q No. (/12 Gl s1� '" aa Fee Er THE COMMONWEALTHbF MASSA&HUSE7TS Entered in com pute;�-G PUBLIC HEALTH DIVISVON -TOWN OF BARNSTABLE, MASSACHUSETTS Yes j ZippYication for Mi5po5a[ 6p.5tem Conotruction Perron Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) 0 Complete System gindividual Components Location Address or Lot No. Mote ff, Owner's Name,Address and Tel No. 0040V,ilc (6rrioh f'rma4 Assessor'sMap/Parcel lY Installer's Name,Address,and Tel.No.S-08-2NO--77_f2 Designer's Name,Address and Tel.No. ✓os�Pti De l3�aw�aS , rrlt�r�e�r«+fir �t�/�°rks' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Y,7 '-i gpd Design flow provided l� 39. gpd Y Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Z C fA 4 j © r- Date last inspected* Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by iAr- - Date V Application Disapproved by: Date for the following reasons Permit No. 8'' 3 Date Issued (� t s4 No: � ..;,7�.� h �`� FIr ��(f *tlr�.t y (,� td` Fee 4 µ^ � � � �� -""� Entered in computer :�► ' - THE COMMONV4'EAL-TH OF, MASSACHUSETTS P ! Yes PUBLIC`HE NTH DIVISION "i•OWN�OF BARNSTA ILE, MASSACHUSETTS Ytcation for tg--6al 6 4tem �Coktruction Permit t Application for a Permit to Construct O Repair.( )� Upgrade O Abandon O ❑Complete System Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. OS'feev,lle, (3r�wti S'wf r! Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 9 Designer's Name,Address and Tel.No. ✓o s'e/04 C>� {3,q?WO 5 r-hg�H C� 1,r� 4f rks CW, Ayl / t 2 o t /c1 o i=5lrfa�� Type of Building:, Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) E Other Fixtures Design Flow(min.reaquired) Y ( q gpd Design flow provided J gpd �. Plan-.Date Number of sheets Revision Date Title t Size of Septic Tank Type of S.A.S. ` Description of Soil f` Y . Nature of Repairs or Alterations(Answer when applicable) Zh41f�1'/'TfJOd (9*/ r 0,00--/r4l /-/-210 i Date last inspected: Agreement: �. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ' accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date / A tic' ti n A ': Gl a o roved b PP PP Y �0��'` � /1 �r�.�� Date Application Disapproved by: _ Date for the following reasons Permit No. )Coe— 13 S,� Date Issued 0� q/U/0i f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) i Abandoned( )by t S,�,dL, �i &Ay-ej 5 at )W,0iH Sr has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 02 dated Installer ee,� Designer #-bedr o cYinn pc e p 1 �I ,, �l(�f Approved design flow' ji f ,� gpd The issuance of this permit shall nD be cons guarantee that grtruedra a the system will fupoitn- �, signede, Date Inspector �� ------------—— -----------------�-/L—r--------- No. �cY - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Migpogal 6pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair 1(�) Upgrade ( ) Abandon ( ) System located at qcl ��aiH S� oSr�r't/i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her PP im duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction_must be completed within three years of the date of th' perm't. t,� J r Date !I f`/U Jl' Approved by ,� No.X... ........ Fxs... ....1s.00...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town O F....................Barnstable ............................................... ......................-----...........--------........----------...... Appliration for Bispusal Works Tonstrnrtinn umit Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: �.>..Mai ...Street,. Osterville•,-�--••-02655 ....- -------- ...................................••-------------..........------....---...----......--•-----.... Location-Address or Lot No. Swift Market 705 Main Street, Osterville, MA .026 j _... ..................... ..•.... Owner Address a A & B Cesspool Service 128 Bishops.Terrace, Hyannis, MA 02601 ................... Installer Address d Type of Building Size Lot...... ...................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building No. of persons Showers a YP g ---------------•--••-------- P ( ) — Cafeteria ( ) a, Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................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........................ 04 ............••••-••-•••-•••••-------•-•..............................••••------....---•----•................................................................ . ODescription of Soil.Sa.nd..........................•••--•-•------•-•---••--•-•-•--........---••-•-•--•-•--••••-•------•-•-•••-••-•--...............--•••--•--•----•--•-•-----------••- W U Nature of Repairs or Alterations—Answer when applicable-1,000--. 11on•septic... ank,.-distribution_. box-•and 1-,OOQ_. alb Qn..heavy....luitY--. ...-•----------•-----------------------------------------------•-....... 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 place the system in operation until a Certificate of Compliance has been i trec by the bo d f✓' 1 26 84 ................... Application Approved By.. ---• .. .. .::. ................................... ...........1�2.el�e? ............ -•.............•-•-••------ Date Application Disapprove or a following reasons:.............................•--••--------------------••---•------------•-••---.........._........._....------ ..............•------•-•-----•--•.................•--••••••.........-----........--••-••--......_..........--•-•-----..............--•••----•-•-•----••--------•-••. ••--•---- - ......-•-------- Date Permit No.......84 ........................................... Issued....1/26/84 ..... Date Noy �.� . _ _- � • . __,_. a.-,. _. Pr!J- --• Fms...4...1.5..Q0..... THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH 7 .M.o .............OF......................Pxxts-table........................................ Allp iration for Mipoii al Works CSonotrnr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: Q ..iYlain..Stxe�t.,...0 �e ra 11 .....026655...... ...................•-----------------.....---•---....-•----------.............---•--------........ Location-Address or Lot No. .............................................. 705....W-11.-Stmeet,..Late=iUe,..XIA.....02L 5... Owner Address aA--&-- ..0 ea6p.wl..Sa rd ae............................................ i2R..I?ishops..Te=aca,..=tLvann1 a,... Y,.....0?601..... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers a g --------------------------•- P ( ) — Cafeteria ( ) dOther 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................minutesp er inch Depth of Test Pit.................... Depth to ground water........................ 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... 1:+ ------•-•--••-------•---....----•-•---.......-••---------•------------------------------------------............................... 0 Description of Soil...Sara..................... x U ----------------------------------------------------•------------..........----------....-----------....------..---------------------------------------------.............----------•------------------- w VNature of Repairs or Alterations—Answer when applicable._ A.,000.-tallw_..septic--.tank,...d.istrtbvt ions. .box.and..1,.000--gala.on..heauy--dudty..le-aah..$it...(arerf1m)........--•------------•------------•...................••-------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL i, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complianc, has been issued bythe boarrdd of.l aI ., i/I ,-- ' Si ne �------. G�. >4 -•- `r /c....._� �� / Date ApplicationApproved B ......... ,:------------.......................................................................... .... 1 ........ Date Application Disapproves d fkg-following reasons-------------------------•---------------------------------------------------------------._... .. ...-----•---------------------.. -----....--•-••-•------------•----•--------------•---------...-------•---...........-------------------------•--------------•------------•---•--------•-------- Dan Permit Noa' .-----------•----------------------- Issued_....1�2�,�� -----....--------•--. f .................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH ........................ .Wn........O F...........Pk�= bsib 1�............................................... Tntif iratr of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by_A-- ;- Cesspool-_Service,_12B__??isho.. .....rice-,---Hy_ann .$1..nA...__ (9.i............................................. Installer at........24S...P11a n.at.+.a..Osterville. .r:�A 0260 _--E.u.C.�...Swi t_T'(arket... has been installed in accordance with the provisions of TIT I�'�ff The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....8....._.. .. dated_...____.1�?6��- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI F yNCTION SATISFACTORY. EDAT ....:�L!.!...��,1.......................................................... Inspector--•--- --- ..................•................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :' ..........Torrrri.....................OF...........'�arnstable.........---•... k NO...................... FEE...`7...._5.00... MsVoii al Works Tono#ru #ion rrnti Permission is hereby granted.....A.A.$..CesspoGl-SPrvice..................................................................................... to Construct ) or Repair ( X) an Individual Sewage Disposal System at No........7o-5--T,A n St , Osterville, !,% 02655 - E.E.Q.•-Swift- 14arlcet Street as shown on the application for Disposal Works Construction Permi�-,0 1__�6 -------f' Dated------- - -1........................ ,7/ ---•-•--. -... ---- Board of Health DATE...--•-----2/-------/84................................................. � 1 FORM 1255 A. M. SULKIN, INC., BOSTON - t IN*. No:»1!.:.1 '7..-- FEs... ....1 j.00...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ...........................................O F............................................... Appliration for Bispasal Works Tomitrnrtiun Vrrmit i Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal I System at: �1............................Man SteeOsterville 0 ,... .,.. 2 !...............•--•-----•----••----•-.....---•-•........--.... Location-Address or Lot No. E. E. C. Swift Market 70 ....Main Street. Osterville. -MA -0265 j__ Owner Address a A & B Cesspool Service 128 Bishops Terrace, Hyannis, MA 02601..................................... ll Q Instaer Address i Type of Building Size Lot......................:.....Sq. feet a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 4 Other fixtures .... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. } Septic Tank—Liquid'capacity.._...._....gallons Length................ Width................ Diameter................ Depth................ [ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. '> Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-•••-•••-............................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ C 4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ d ........................................................................................ ........... --•-----•---•--------•------•------••-------•-•-------•••-•-•.....----•-------•••- Description of Soil.Sand................. i j ................................••._......_.....--•--.............-•-•---•------....--••-•-_..........••--••---••-•--...._...•-•......---•---•••-•-----••--••--_........___...----••-----•--•------.••... `I -•--•----•.........................•------••---•--------........... •--•--....---••--•--•--••------•---•-•-------••-•----•-----•-•-----........ j Nature of Repairs or Alterations—Answer when applicable._1_A 000•..ga_i),or�._septie__taij distribution_•. b ox•-and 1-,000._g�l�on..l�eaVy.--d ud..ty--1e.a Q z--P t �5?Ye f�o ) •----•-•-------•-----------------•---------------------••-----------... € Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with } the provisions of TITLE P 5 of the State Sanitary Code—The undersigned further agrees not place the system in } operation until a Certificate of Compliance has been is fired by the bo d gned:+ ' ..... .-•------ 1/26/8G......__• --..... . ........... Application Approved By.. --•• •. -- '.::. .......................•-•----•----------•-•----...........----- ........... ....- Date Application Disapprove . or a following reasons:------•-•-------•------•--------------------•-•-••-----•--••-------••--•--•....•--••.....• - -•---•---••--••..........................•-•--.......---•----•-•----............--•---....................---•-------------•--•---...------...---•----------•-•------•------...---•• ••--.......••... Date Permit No......84-------------------•-------•-•-•---------.. IssuecL..1/261.84 _ ......•-------------------•---. Date n.e —e u u a n—.s.s.0 f Engineering Works EXISTING FLOOR PLAN f2 W. Crossfield Road 699 Main fit., Osterville, MA Forestdole, MA 02644 Job No. 112-08 Date: 2/22/08 (508) 477-5313 Page 1 of 1 3 0 OFFICE BREAK RM. a, STORAGE LOFT i c a� Q 0 Deck 1180±S.F. 865±S.F. SECOND FLOOR THIRD FLOOR SUPERMARKET 3320± S.F. Deck Ramp FIRST FLOOR 04 1'5/20H 05:45 5084775313 ENGINEERING WORKS PAGE 02 Town of Barnstable Regulatory Services Thomas F.Geiler,]director Public Health Division Thown McKean,Dir"tor 200 Main Street, 11YORnis,MA 02601 tom: 509-9624644 Fax: S08-79"304 Date: Sewage Permit## Assessoes Maj dPaInm:l ll' er: I et1 �, j r: 'I !� . �� S Addren: { Address: (2 �_ On Joe� $ C 90/i_ewas issued a pemit to install a �sepxic system at e S� 40 based on a desi r.drawn by address y r 1. tart dated Z�-I OT ' ` e (designer) I certify that the septic system referenced above was installed 31fttftfttWJY WMfding to the design, which may include minor apprtrved changes such ass honal region of the distribution box andlor septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic stem referenced ;eve was installed with r�;�►ar changes (i.e. smater than 10' la�sl reation of the SAS or any vertical t 'Guy�mporrent of the septic system)but in accordance.with Mate & Local e �' n revision or certified as-built by designer to follow. Stripout(if requ' % d the soils were found satisfactory. T. Z McEWEE No. 35109 (I er'SSignature) UM (I rimer s Signature) (A x siVW 7S Starxtp Vie} PL li�E B TAIL TH D a C C C ARE E Y lg MT I q:1Dffkz f dM - Tot�vn of Rairus able r# Department of Regulatory Services Public Health Division: Hate c � (� IQ Main:Street,'Hyannis MA:0260Y Dheduled _" ... 'Time. ate-Sc • : Fee)'d_1 f cn ... - 2 .2"M Soir Suitability Assessment for Sewage. cl , Performed-By: :; ,Witnessed-By I LOCATION:& GENERAL INFORMATION '' w' l.ocati©n,Address � .9 yVJ ct t n C�i Cgs Owner's Name 99 q C s� 4C. r r- Addres o r^ Assessor's Ma.'p/Pargel:•. '(� f ( Engineer's Name NBWCONSUt;'I'ION REP1AIR :.. Tel b' Telephone# CO "4 7j� Cof11 W\2 r��.a` Surface Stoaes ` . Land Use Slopes(%) _.G 1 7 30 Q ft Possible Wet•Areal g Distaneeilrom: Open Water Body 7 ft Drinktn Wafer well Drainage y 7I0O Ufe5- t Other..Wa o fppy $IKETCH .(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlaa a proxrmtty=to holes] L _ I ��t v`9�t1 • t N . c .STo �DIVDIK) Parent material_(geologic) `a 4 ®'�� Depth to Bedrock `S/ ` Depth to Groundwater: Standing Water in Hole: �`/ Weeping from Pit Pace ~` Estimated Seasonal High Oroundwater °�7 DETERMINATION FOR SEASONAL HIGH WA,TR' , Method Used: :. Deptfi Observed standing in obs.hole: -In, Depth to"oil m944ds, In Depthlo,weeping ftom side of obs.hole: i;, Groundwate Ad).re�Mtp^' fk. [ndex.We11 if Reading Date: index Weli level.., Act fltctor,,,,,, �..;�cQ p>quti�►tgrt.eYel`,,,:. PEACOL,ATIt MT 4"= Hole:lt - - U is Depth of Perc d D/1 1Yme at 6" Start Pre-soak Time® Time(9"4) .. .....,. End Fce-soa)C �1 i��(l� Rate.Min./Inch APM Site.Suitabtlity Assessment: SitePassed Sits Foiled: _ Ad dition.al;Testing Needed(Y/1-1 i Original-*Pobtic Health Division Observtition Hole Data To Be Completed on Back -------- ***If percolation test is to be conducted within 100'' of wetland,you must fist ltte= Barnstable Conseirvation Division at least one(1)week prior to beginning: DEE- ROBSERVATION HOLE LOG Hole# l Depth from Soil Horizon Soil Texture Sdil Color. Soil• Other Surface(in) (USDA) (Mttnsi ll). Mottling (struetue,Stones;l;.ouldet$. new f ,za send . Z� Y0 77— OEE. ON ERVATION HOLE LOG Hole# z SoIIHorizon . Soil Texture; Soil Color Sgil Other Surface(in:)' (USDAA.) (Muriecll) Mottling (Structure;Stones,Bouldets; . mud Z* 5 a ?, DEEP OBSERVATION HOLE LOG Hole# OR 1 SbillHerizou Soil Texture Soil tralor. SoII p $ufPaCe{in) (USDA) (I4lunselq Mottling (Sdvcture,.Stonee,Bouldas. • EP OBSERVATION HOLE LOG Hole# Depth from, Soil tiodzon Soil Texture 3oil•C6lor Bail . Other $uiface (USDA) (Munsell) Mottling (Structuro,Sto les,Bouldm. Flood•Insuran ef_. e M AbOVeiO .y flood`�oUn. dory' No _ withitr3o(l year boundary No i Yes 3i Widiih4ly. r�floctdboundary No! D�Ath of,�,gtaut Q---I�---Q Pe loos e' e 1 awl��"'f l"��•S�wri.+y�L�lwi Dnes of least dour feet of naturally occurring pervious material exist to all areas observed thrpugiout the area;proposed for�the soil absorption system? �7°�S If not,what is the depth of naturally.occurring pervious matorial7 �` Gert_ i8catto� . ,�" I certi that:on �f 4 a� _ . fy (date)I have passed the soil evaluator examination approved by the department of Environmental Protection and that the above analysis.was performed-by iris consistent wlfi . �' a required training,expertise and experience described in !0 C1VlIt 15.017. Signature - - lT lob Q•1S.Ei''J't(:'tP13!$��F�&�1NI�bC J x. pC6_R WED EB Zj S r Septic System -Inspection iZeport f e Li a. ` _ Y 699 Main Street Osterville,Massachusetts t`' .. � 1 , r S t `• � t 7 � r e T �� l Ja� aary 29 2002 1 "J Yry 5 t it 1� k is•' ;.z k - De:^R e J LOT i ,rr - ;� ^a a tf Cartier.Tatibouet a Post Office Box`5. 5 S % r r •� 7 4�r ' Cuinma uid;:Connecticut, 02637 �< ci 51 t rf v a- it a� r y �� •9 t � f `• .. � t XV 3 , r G ' Providing Innovative Solutions,For ~r { ' Solid Waste k ` _ Health&Safety y "' t tHazardous Waste` Environmental Monitonngl, Materials Management' Compliance 0utsourcingwr S ?3, aw ;. ~Yf `,�S,t �: - F'.r ..a •:,,K i .I �w,,:�r `<,.' '+f r _ } fie' S:'lh , ',4 ati'.' www green sealenvironmental com r Phone: (SQS) 888-6034 ,' i "Fax:.(508)888-15Q6` t jxa 28�Route'6A,rSandwich,MA'02563 1 COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION V � P 1 Lar TITLE 5 ' OFFICIAL INSPECTION-FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ' CERTIFICATION Property Address: 699 Main Street,Osterville Owner's Name: Cartier Tatibouet Owner's Address: Post Office Box 555 Cummaquid,MA. 02637 ' Date of Inspection: January 29,2002 Name of Inspector:(please print) Terry F.Bauer,PG Company Name: Green Seal Environmental,Inc. ' Mailing Address: 28 Route 6A Sandwich,MA. 02563 Telephone Number: (508)888-6034 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my ' training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ' X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspectors Signatu : Date: February 1,2002 ' The system inspector shall submit a cop of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments The system appeared to be functioningas intended on the day of inspection. Please note Y P that leaching from the SAS appeared to be slow based on the level of ponding and the lack of use of the system for approximately 10 hours prior to the inspection. Proper maintenance and care of the grease trap is essential to the proper functioning of the system. ' ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. i Page 2 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 699 Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D ' A. System Passes: ' X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system appeared to be functioning as intended on the day of inspection. B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ' ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or ' obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed ' distribution box is leveled or replaced ND explain: ' The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ' broken pipe(s)are replaced obstruction is removed ' ND explain: 1 ' Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ' Property Address: 6"Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 ' C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system ' is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: ' _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ' 2. System, yste will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ' The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. ' 3. Other: I 1 ' Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 699 Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 ' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: ' Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool (no"D"box in this system) X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. ' — X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] ' No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) ' yes no T _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped ' Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a ' significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 1 Page 5 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B CHECKLIST ' Property Address: 6"Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 ' Check if the following have been done.You must indicate"yes"or"no"as to each of the following: ' Yes No � X Pumping information was provided by the owner,occupant,or Board of Health(Sewage Treatment Plant) X Were any of the system components pumped out in the previous two weeks? ' X _ Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? ' X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition ' of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CUR 15.302(3)(b)] ' Page 6 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ' Property Address: 6"Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 FLOW CONDITIONS RESIDENTIAL N/A Number of bedrooms(design): Number of bedrooms(actual): ' DESIGN flow based on 310 CMR 15.203(for example: l 10 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): _ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd): Sump pump(yes or no): ' Last date of occupancy: COMMERCIALANDUSTRIAL ' Type of establishment: Grocery/package Store Design flow(based on 310 CMR 15.203): Unknown(no design plans on record) Basis of design flow(seats/persons/sq. ft,etc.): N/A Grease trap present(yes or no): Yes ' Industrial waste holding tank present(yes or no): No Non-sanitary waste discharged to the Title 5 system(yes or no): No Water meter readings,if available: 2000—111,000 gals(304 gpd),2001—93,000 gals(257.810 ' Last date of occupancy/use: Currently in use. OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Barnstable Sewage Treatment Plant—No pumping records from 1993 to present. ' Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_____gallons--How was quantity pumped determined? Reason for pumping: ' TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system (includes a grease trap) _Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be ' obtained from system owner) _Tight tank ^Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Original'installation date unknown. System modified to include a grease trap in 1997. Information from ' Health Department files. Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) ' Property Address: 699 Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 ' BUELDING SEWER(locate on site plan) Depth below grade: Below building slab. Materials of construction:_cast iron X 40 PVC other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): ' Unable to observe sewer due to its location beneath the building slab. SEPTIC TANK: X (locate on site plan) Depth below grade: 4 feet Material of construction: X concrete_metal_fiberglass polyethylene_other(explain) If tank is metal list age:_ Is age confirmed bya Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: &5'x 5'x 4'(1,000 gallon capacity) Sludge depth: 1" ' Distance from top of sludge to bottom of outlet tee or baffle: 3'10" Scum thickness: Intermittent scam laver Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle:N/A How were dimensions determined: Direct measurement Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Noigumying recommended at this time. Inlet and out tee's in good condition. No leaks in tank apparent. Liquid level at outlet invert. Recommend installation of Zebel filter assembly(or equivalent)on the outlet of the septic tank. ' GREASE TRAP: X (locate on site plan) Depth below grade: 2'6" ' Material of construction: X concrete metal_fiberglass_polyethylene_other (explain): Dimensions: &51x51x4'(1,000 gallon capacity) Scum thickness: 1/4"(intermittent,however,signs of a grease line at outlet invert) ' Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: 16" Date of last pumping: Unknown. No records available at Sewage Treatment Plant. ' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):No recommendation for pumping at this time. Pumping of grease trap should be conducted in accordance with Title V requirements. Inlet and outlet tees in good condition. No leaks in tank noted. Liquid level at outlet invert. Recommend a Zebel filter assembly(or ' equivalent)at outlet to grease trap. r Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) ' Property Address: 6"Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 ' TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: ' Material of construction: concrete metal fiberglass ipolyethylene other(explain): Dimensions: ' Capacity: gallons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): ' Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) ' Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of ' leakage into or out of box,etc.): ' PUMP CHAMBER: N/A (locate on site plan) Pinups in working order(yes or no): ' Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6"Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 ' SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: ' Xpe leaching pits,number: 1(unknown amount of stone) leaching chambers,number: leaching galleries,number: ' leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: i ' innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Unable to observe soil due to depth of SAS. Ton of SAS approximately 812"below the surface. Pondina at 2 ' feet in depth in SAS,leachin¢appears to be slow. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) ' Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: ' Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A (locate on site plan) ' Materials of construction: Dimensions: Depth of solids: ' Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: 699 Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 ' SKETCH OF SEWAGE DISPOSAL G SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. ' Please see attached sketch 1 1 1 1 1 1 1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: 699 Main Street,Osterville Owner: Cartier Tatibouet Date of Inspection: January 29,2002 ' SITE EXAM Slope: Moderate slope in SAS area.but SAS over 8' below surface. Surface water: None in area Check cellar: No water Shallow wells: None in area Estimated depth to ground water 2410 feet(below the ground surface at,the SAS) ' Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ' Observed site(abutting property/observation hole within 150 feet of SAS)) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ' X Accessed USGS database-explain: You must describe how you established the high ground water elevation: ' Seasonal high groundwater was determined by reviewing USGS/Cape Cod Commission indicator well data for the site area and comparing it to site information. The elevation of the surface area was determined to be ' 35 feet above mean sea level from the USGA Topographic Map of the Hyannis Quadrangle. The SAS bottom was measured to be approximately 14 feet below the surface at elevation 21. The USGS map entitled "Groundwater Resources of Cape Cod" (1986) indicates that groundwater can be ' encountered at elevation 5,which is approximately 33 feet below the surface at the SAS or 29 feet below the bottom of the SAS. ' Using the Cape Cod Commission method to estimate the seasonal high groundwater elevation, the site was found to be within the area of groundwater indicator well MIW-29(Zone C). According to the most resent data available(Cape Cod Commission web site) the January adjustment for that well is 5.2'upward. When subtracted from the separation between estimated groundwater and the SAS bottom the resultant separation ' is 23.8'between seasonal high groundwater and the SAS bottom. I� ' LOCUS MAP SEPTIC Y& S C SYSTEM SKETCH 143 Craft "Ysic o• ra` 1 < ° !, Bog 6 � 3 BA r nl rry 2 t'• •eta o {• {�4 � 0 � � Cianb®er n��C41y� a`„' ip •'' ! Hete: ry � r.' �`. •y Q 3 a4', '4� • 1 �tBM + Cranb-ry. i • .' �. , ;+ £sad r. �`sJ�we � � 4.• �� (*� c "4tV t 'J � �� f ��f�F �Yipp ` + a. ��. ; � • 1 �' — ' � ` - •'A...r...� �O�• �.(n� (e l�•'A ??,�{ (�. 'C y �..'^'"ti':+...J ✓6� � - ��,/• 2G+' `C- ' � 1� r.. Wl ,•' , e, - , �i1 Y e`� Micah '4{;`u •.: a W - `�t��uwp') �'� ` n�p`.4'h �.� '�' � � �� 12 �� p/ y;• •rt� - 'R \ O �"{.""„�q, '�i 9� •I tt--i' jr � ll1� � y � y ryv • `' �• :�. •.�3''Q �' Jo►osh �� 'y �� ,y rt .,°.4 �r'.o '�., . • 4b `�jt ;a c • + He latqnd r P ..�, �,�"Q i t;� �, , n '��•`.`�_ .'i. j r�j,•� - x ...i 13atieNa > J 1.1 _.�. , � 3 q 'ter •R '� � u x �+a 'kAL 3' tl fit, r'•' aj 2 It 8 � � ••� T, ' 'o�p �r,~sy�`.' n Ga a �,�+ .i �,,:. ,< .a ¢ a . •Y , �,. v z = o East Bad/ 7 z owse 1 . '• -�� ni'' ! •'.d`�y �''''` ;7 RBI' • •tp"a9� I - ° Beach Oyu 6 l� F - ;'�''+i 4IZ(� 0gs�;ma�s a P9 • g,�8��' ' ♦ 6 8 { t -..•' • k" o q,AV ' it: "' �,�r' . r l r'"�..•,..,'� o •:{�,� � tin r'ti- ix...e:... �: •••• 2 - ��• J4.1 6 9 1 • • •�"r�,, xt":``•u,n / 1 .t) W ``� i ��.N�4 of �.ji4*`•. 6 1 Name:COTUrr Location: 0416 38'17.2" N 070°22'57.0" W Date:2/1/2002 Caption:Locus Map Scale: 1 inch equals 2000 feet 699 Main Street Osterville,MA. ' Copyright(C)1997,Maptech,Inc. Septic System Sketch ' Cross Section ' ground surface , 8' 2,r�' (Note: SAS cover Foundation 4' is H2O rated & very heavy. - Two feet below surface to ' Grease Trap SAS riser.) Septic Tank ' Slope 23.8' ' 1 Adjusted Groundwater Septic Tank Grease Trap ' Concrete Retaining SAS Walls A ,tio Flat * Estimated Ramp ti \ U - (higher in Distance Area elevation than ' ramp area) I,I Slope I , #699 ' (EEC Swift - Groceries & Package Store) 1 Main Street r n D Location: 699 Main Street �� ♦� Osterville, MA. Figure2 Date: January 29, 2002 Not to Scale �� O Based on Visual observations i i I , Town of Barnstable o�► ►o,;� Regulatory Services �04 Thomas F. Geiler, Director !: 0,1RNbTABLB,I:!I public Health Division '\�� NARS i63 go. \Eo► ��' Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 I ' MAIL'I'0:'I'OWN OF BARNS'IAHLI: PUBLIC HEALTH DIVISION 200 MAIN STRFFT ' I IYANNIS,MA 02601 FAX: 508-790-6304 ' SEPTIC SYSTEM INSPECTOR REGISTRATION I ' Date S 0 "L ' Name of DEP Certified Inspector _ Business Address 28 Ro ttn< A- , 0 Z 5� 3 Business Telephone No. (5o8 ) 638 ' FAX Number (�C6 ) des - 150(0 Home Address 21 2,4 Staez-ET kf 4 QIU4-5QIU4-S Home Telephone Number(508 ) ¢�-18 Z9 The undersigned agrees to comply with PART VIH, SECTION 14.00 of the Board of ' Health Regulations. 'The septic system inspector shall complete every applicable section of the"Title 5 Official Inspection Form-Not For Voluntary Assessments, Subsurface Sewage Disposal System Form," supplied by the Massachusetts Department of Environmental Protection. In addition,at the bottom of the last page of this official inspection form,the septic system inspector shall provide a sketch diagram showing the vertical separation distance between the bottom of the soil absorption system and the groundwater table along with any high groundwater elevation adjustments determined. The Septic System Inspector shall submit a copy of the completed septic system inspection report along with the required processing fee to the Public Health Division Of-ice within 30 days of the inspection date' Signature of Applicant w in THE COMMONWEALTH OF MASSACHU SETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT . Terry Bauer Oas satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR a provided in 310 CMR 15.340 and Section 13 of Chapter 21 A of the G neral Laws. Issued by The Department of Environmental Protection. October 3 n 1996 it for of the i sion of Wa AL Pollution Control vc46 Commonwealth of Massachusetts RECEIVED C Executive Office of Environmental Affairs p E C 3 1 199 Department of Environmental Protection Wllllam F.Weld `` Governor roe?Jg Trudy Coxe Secretary,ECEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION . 05CjO"'v'� Property Address: _r ° l t S Address of Owner: Date of Inspection: ()Ia t av Q�, (If different) Name of.Inspector: W tallt f16-W S clr wCompany Name, Address and Telephone Number: _ J CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: �� Date: � ay �G The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: A One or more system components need to be replaced or repaired. The n completion of the replacement or repair, pas s ction. Indicate yes, no, or not determined ). Describe basis of determination in all instances. If"not determined", explain why trot) The septi is metal, cracke , s II unsound, shows substantial infiltration or exfiltration, or tank failure is nent. The system will pass inspection i t isting septic tank is replaced with a conforming septic tank as approved by the Board of Health. - (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-?049 • Telephone(617)292-5500 Printer)on itec yc% i Paper t, , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: )r Date of Inspection: B] SYSTEM CO�DITIONALLY PASSES (continued) _ Se g backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due tb a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are rep°,aced obstruZfioQ<7moved distribution boz-is levelled or replaced _ The system required pumping more thawfour times a yeas due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ,i bo struction is removed C] FURTHER EVALUATION ISsREQUIRED BY THE BOARD OF HEALTH: Conditions exist,hich re uire further evaluation by the Board of Health in order to determine if the syste is failing to protect the public heal;safety and th environment. 1) SYSTEM¢WILL PASS UNLESS B \50feet ALTH DETERMINES THAT THE.S . EST M IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUH AND SAFETY AND THE EIV'IRONMENT: Cesspool or privy is witf a surface water Cesspool or privy is witas bordering veget t d wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (At-D/PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT ST E THE SYSTEM IS FUNCTIONING IN A MANNER T PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and sort absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. X The system ha, a septic to/k aand soil absorptions system a cl s within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is�within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless/well water analysis for coliform bacteria andivo�latile organic compounds indicates that the well is free from pollution from that facility an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have)i etermined that the system violates one or more f the fof owing failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Ith should be contacted to determi wh will be necessary to correct the failure. Backup of sewage into facility or stem component ue.to an overloaded or clogged SAS or cesspool. Discharge or ponding of luent to the surface of the ground or surface waters due to an overloaded or clogged SAS or g cesspool. Areviaed 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO RM PART A CERTIFI TION (continu Property Address: Owner: t Date of Inspelction: D)SYSTEM FAILS(continued): _ Static liquid level in the dist i utio.n-bo�bove ou vert due to an overloaded or cl, SAS or cesspool. Liquid depth in cesspoo is less t an 6" below invert or available olume is less tan 1/2 day flow. Required pumpin more than 4 times in the last year NOT due to clogged obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is belo the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surfa water supply or tributary to a surface water supply. IAny portion of a cesspool or privy is within a Zone I of.a ublic well. I Any portion of a cesspool or privy is within 50 feet a private water supply well. Any portion of a cesspool' or privy is less than feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the wel as n analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compo ds, amm nia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large sy ems in addition to the criter above: The design flow of system is 10,0 0 gpd or greater (Large System) an\�e system is a significant threat to public health and safety and the environment because�o or more of the following conditions e�,ist: the system is with/in 400 feet of a surface drinking water supply the systems within 200 feet of a tributary to a surface drinking wate supply the sysfem is located in a nitrogen sensitive area (Interim Wellhead Prote ion Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operas/or of any such system shall bring the system and facility into full compliance.,,with the groundwater treatment program requirements 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. i (revised 8/15/95) 3 r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: , Owner: /',- e- 5 Date of Inspection: D e c _ I Check if the follow' ave been done: a ' _Pumping information was requested of the owner, occupant, and Board of Health. 4ZIN-one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rams during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As buil ans have been obtained and examined. Note if they are not available with N/A. he f ' iry or dwelling was inspected for signs of sewage back-up. The sys -does not receive non-sanitary or industrial waste flow e sit s inspected for signs of breakout. -All syst components, excluding the Soil Absorption System, have been located on the site. he septic t manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, erial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or appro i ated by non-intrusive methods. _The facility o,•:nee (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 _77 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: C--!; Date of Inspection: l FLOW CONDITIONS RESIDEN AL: Design flow: allons Number of bedr s: Number of current re nts:_ Garbage grinder(yes or Laundry connected to stem (yes o Seasonal use (yes no):_ Water meter r ings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL: �Type of establishment: C�cC"�°6(� J �v�e Design flow:_gallons/day Grease trap present: (yes or no)_Z� Industrial Waste Holding Tank present: (yes or no)&� Non-sanitary waste discharged to the Title 5 system: (yes or no) /V*Water meter readings, if available: l _ / �� 6 ��/95 Last date of occupancy: OTHER: (Describe) Last date of occupancy: . GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: eallons ;Reaso umping: TYP SYSTEM Septic tank/dist4bdtiort-bo:dsoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: f Sewage odors detected when arriving at the site: (yes or no)Le (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5Aq t1 Owner: & F C S' 1 Qt Date of Inspection: SEPTIC TANK:_ V (locate on site plan) E Depth below grader Material of construction: concrete _metal _FRP_other(explainr Dimensions: Sludge depth: O Distance from top of sludge to bottom of outlet tee or baffle: d Scum thickness: - Distance from top of scum to top of outlet tee or baffle; — Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of'inlet and outlemees or baffles, depth of li uid I vel in relation to outlet invert, structural integrity, evidence of leakage, etc.) �/ GREASE TRAP: (locate on si L Depth to ade: Material o stru io - c ncre a _m _ _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom rn Fruni In bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, e:c.) (revised 8/15/95) 6 � SEPTIC TANK DEPTH BELOW GRADE _ -� _____--__ DIMENSIONS SLUDGE THICKNESS � TOP OF SLUDGE TO BOTTOM OF TEE p SCUM THICKNESS TOP OF SCUM TO ,TOP OF TEE BOTTOM OF SCUM TO BOTTOM OF TEE DISTRIBUTION BOX DEPTH OF ABOVE OUTLET INVERT PIT BELOW GRADE BOTTOM OF PIT TO GRADE CESSPOOLS '7 NUMBER AND CONFIGURATION TOP OF LIQUID TO INLET INVERT DEPTH OF SOLIDS ' LAYER DEPTH OF SCUM LAYER DIMENSIONS OF CESSPOOL MATERIAL OF CONSTRUCTION INDICATION OF GROUNDWATER INFILTRATION ( ) MUST BE PUMPED ----- ----------- r Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TA (locate on site plan) / Depth below grade: Material of copstruction: _concrete metal _FRP other plain) <4 Dimensions: 1 Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float swi es, .) if DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution i;equal, idence of solids carryover, evidence of leakage into r out of box, etc.1 PUMP CHAMBER:_ (locate on site plan) Pumps in workin rder:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible,- excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: � leaching pits, number: thing chambers, num _ lea ' galleries, n r: leaching the , number,length: leaching fie tuber, dimensions: overflo cesspool, ber: Com s: (note condition of soil, signs o draulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (loc to Ian) Number and configuration: Depth-top"of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must la pu as part of inspection) Comments: (note condition of soil, signs of by ti failure, level of ponding, c ition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of veg on, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 o5fpeui,Mt t Owner: C7 F e S cZ ��'`f ..-� �O��`/✓�N J ,Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 9� DEPTH TO GROUNDWATER Depth to groundwater. feet / method of determination or approximation: .7 � O (revised 8/15/95) 9 PREVIOUS OWNER'S FILE BEFORE 2014 IN ATTIC Bellaire, Dianna From: info@fancysmarket.com Sent: Tuesday, November 24, 2020 10:18 AM To: Bellaire, Dianna Subject: Tobacco products at Fancy's Market Good Morning Donna, This email is to inform you that Osterville Market Partners, Inc. doing business as Fancy's Market does NOT sell Tobacco electronic delivery, e-cigarettes or juices. Have a great day. Kathy Robertson Office Manager Fancy's Market 699 Main Street Osterville, MA 02655 508-428-6954 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! 04/15/2008 05:44 5084775313 ENGINEERING WORKS PAGE 01 y Town of Barnstable Regulatory Services Thus F.filers Dir"Jor sea# f Public Health Division Thomas McKeae,Director 200 Main Street, Hyannis.MA 02601 Old(sos-Ka-4644 Fax: 500-790-6304 Date: f—Z:OS Sewage Permit# �. Amessor's MxPfflarcd 1 IMMSgff r r • Inata�r: .�o `S � �t � . Address: VJ . C ps A C�. bda le�.C1 A 02 sty on /^ 68 ' was issued a permit to install a septic system at ��a 0 '�"• based on a desist:drawn by 4-er'f: t? dated igner) X I certify#hat the septic system refereauced above was installed mtbs� to the desip, which may include minor approved ahanM such as latoW the M 111button boa and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic ssyystem re fe acod above was installed with ma* dMUM (Le. grater than lo, lateral relocation of the SAS or any vertical of the septic system)but in accordance with State&Local ravismn certified as-bolo by designer to follow. Stripaut(if requ A ati ils wom found satisfactory, PETER T. ar, MCENTEE o CIVIL No. 35109 az { bswiefs S ,e) igner's tgna�ure) ( x igner s Stamp ) PLFAM RE TO 2 Nfly B ION Y BARNSTABL P $, aMMdM � 1 F b LEGEND 9 10 o N 97,24 X EXISTING SPOT GRADE \ rn —— 92—— EXISTING CONTOUR \ a L„ Ook Q. Wy EXISTING WATER SERVICE G EXISTING GAS SERVICE 9 3 \ p6 � O.H.W. EXISTING OVERHEAD WIRES �i 91 3 /� 4- � � o E PROPOSED ELECTRIC SVC EXISTING WATER SHUT-OFF I �' 31! \� ~ Main St o EXISTING GAS SHUT-OFF 9�4 O. /� g1 C,S \41 s� � m �� 92 \TEST PITw%onno 3' Rd BENCHMARK g '1u, �t �� !y Ave LOCUS BLDG. ea ' A \ LOCUS NOT SCALE c� s�\_ 8 �0\\ g/ �0 �'o moo. 910 90 BENCHMARK N0.2 8 - o- F CTR. OF LP MH COVER �e 0 / o ELEV: 97.41 (ASSUMED) e O c' o EXISTING 90> BUILDING (#699) S ya A P N 141 — 012 g 1 s. TOF=95.10 � � Illiil111 O.H.W. GENERAL NOTES. g880 0 LOT A 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 7 /�� , _AP_N_ 141 -011 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS g k / �4 ---- OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE BLDG. 846 ,� ° / y> l I I I I I I I I C T WATER METER MH LOCAL RULES AND REGULATIONS. \Ar FLOOR EL.=90.34 3. THE SoilAir BLOWER UNIT SHALL BE INSTALLED IN STRICT COMPLIANCE . 8 II MAW' ' ' ' ' ' WITH THE MANUFACTURERS REQUIREMENTS AND RECOMMENDATIONS. � DRAIN RIM EL.=9O.15 ANY QUESTIONS RELATED TO THE INSTALLATION SHALL BE DIRECTED TO \ Jed ABUTT. SMH NO GEOMATRIX LLC, 114 MILL ROCK ROAD EAST, OLD SAYBROOK, CT 06475 00-1 Telephone: 860-510-0730 o� 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING e / O/ ro �' FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 000 dA ' C ENGINEER BEFORE CONSTRUCTION CONTINUES./ .43 -� 9�2 \� 16$�� J 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. • / rl h. \ �.^� S 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 9 O CONTROL PANAL THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 96,11 954 9IS4 EXISTING DRY WELL HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. \ C PAR G / O 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. EXISTING SEPTIC TANK 8. THERE ARE NO PRIVATE WELLS WITHIN 150' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS z AGREED UPON BY OWNER D CONTRACTOR IT EXISTING GREASE TRAP r �P�� OF MAssq�y DIRECTED BYTHE APPROVING EOR OR AS OTHERWISE S. / 00 > / / F. o PETER T. X 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE e NTEE �� / / McE �?�` o THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING Cl -S�T� '�/ �'04 p� BENCHMARK N0.1 No. 35109 CONSTRUCTION. , a CTR. OF GT INLET MH E cisl T g8 \mo Go ". I 1%EN / e e °�� ELEV: 92.13 (ASSUMED),, P Fs AL `` PROPOSED SoilAir M REMEDIATION PLAN �S T / opµ C� EXISTING PUMP CHAMBER IQ`` 699 MAIN STREET, OSTERVILLE, MA e� PROPOSED POWER TO BLOWER r Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 ABUTTING EXISTING S.A.S. OWNER OF RECORD UP/274A 9 PARKING 4 ROWS OF 6 - 16" HIGH CAP. H2O BIODIFFUSERS Engineering by: Surveying by: SCALE DRAWN JOB. N0. & ) THE 699 MAIN SREET, LLC Engineering Works WARNER SURVEYING = n; P.T.M. 112-08 g8 0 1 ROW OF 5 - 16" HIGH CAP.(H20) BIODIFFUSERS c o BRIAN SMITH 9 9 I�p �� 12 West Crosafield Road 22 Long Road 1�1 PROPOSED SOILAIR BLOWER UNIT 699 MAIN STREET Forestdole, MA 02644 Harwich, MA 02645 DATE ftECKED SHEET NO. 4I CONNECT TO EXISTING VENT PIPE OSTERVILLE, MA 02655 (508) 477-5313 (508) 432-8309 7/14/0 9 T.M. 1 of 1 V1 � W � N oo O oo 0Nb o C O x O EX15TING 2nd FLOOR 5TORAGE 1 0� j f- 51 51 F'� a 2ND FLOOR Lo i NEW BATH j CONFERENCE ROOM ,�+ a EX15T. DOOR. U w PROPOSED HALF BATH PLAN SCALE: 1/4 _ 1,_O,, DRAWN BY: CBH DATE: O/13/15 LEGEND .ri. �. ,� 92. / a c o N q EXISTING SPOT GRADE (� F � 7"24 x -_ 92..... EXISTING CONTOUR y6 PROPOSED CONTOUR / !y t/1 EXISTING WATER SERVICE -- ' --- EXISTING GAS SERVICE EXISTING OVERHEAD WIRES y O.H.W. ; �So EXISTING WATER SHUT-OFF } Z/ }� �31 \� ,° Main St m Of EXISTING GAS SHUT-OFF ��? / '� 91 r'' (1 \� \ a C3 TEST PIT I '4 LOCUS Rd BENCHMARK 1 / Q� �r,,� Ave i�' o �� BLDG? ,_; yea , , ° , s �� LOCUS MAP EXISTING LEACH PIT 0 �/, 707 / / , - , -� / NOT TO SCALE TO BE PUMPED, FILLED W/ �, # Q p. 'i o, SAND;,AND ABANDONED „{ u'a, '60I °x\ /y� �• a� moo,, BENCHMARK N0.2 GENERAL NOTES: CTR. OF LP MH COVER �,, 3' .I / p ELEV: 97.41 (ASSUMED) EXl$TING, 90 1 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL �e o / a BUILDING (#699) S g� BOARD OF HEALTH 'AND THE DESIGN ENGINEER. �\� 00•� s� i IZ 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS APNI 1 41 _ � JOF 95.10 �OCAL THE RULES ANDIR�GULATIONS NMENTAL �pCEPT AS DE, TITLE REQU AND ESTED BELOWAPPLICABLE I V V O.H.W. 310 CMR 15.405(1)(b): 98 / / SU/ � ► LOT A — 1) A 2' variance to the 3' maximum cover requirement, for 5' of 8p ! / / Imo' max. cover. S.A.S. shall be vented and H-20 Rated. "4 / 7,486f S.F. p 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR APN 141 -011 d ,F` y TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE BLDGy8 / o`� / �4 WATER METER MH DESIGN ENGINEER.I � 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 705. r' # / \Ar FLOOR EL =90.34 , / O 6 �+ w FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN j / / / �' e r DRAIN RIM EL 90R15 i ENGINEER BEFORE CONSTRUCTION CONTINUES. m g AL3UTT SMH �� ' / S. ALL ELEVATIONS BASED ON ASSUMED DATUM. o . 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF ' / h 90 �.}"' O THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF o� /�� y `� {'., c? �� 6 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION_ `\ % e . � sk. =� 6 �� . / / 1j 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. e / �0 / c < - 5 /Or, � f / �6 � �'`i .' � 919 �'q ,'s 2�� 8. THERE ARE NO PRIVATE WELLS WITHIN 150' OF THE PROPOSED S.A.S. j 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS O EXISTING DRY WELL AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE j � /11 / 95 4' O 91,5 DIRECTED BY THE APPROVING AUTHORITIES. o PAR G ;��',> 4 / � o / . ,• � � � , � � EXISTING SEPTIC TANK 10, IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE ��S'��a�-S' O' ' INV. IN =86.55t THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING V im`", �' �iZ��(( ' TP2 I. INV.(OUT)=86.3Uf pi A9 CONSTRUCTION. -5I' > T'-2 1 1� qss 11. WHERE REQUIRED, 'CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS � /1 y'��,�' I 1 EXISTING GREASE TRAP IN THE AREA BENEATH AND ON ALL SIDES OF THE S.A.S. AND REPLACE O• �. cfl, �' v �i INV. IN)=88.38i z ✓ / �,''��',�y� -' �' ' INV,�OUT)=88.13t McENTEE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). CIVIL "' 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. �r'',>�,-' ' '$ BENCHMARK N0.1 No. 35109 ` R`�' �^ %' e�. ° � ' CTR. OF GT INLET MH ' o R£G/St�K``v �� -' yet`' 2 Fst, ��G� PROPOSED SEPTIC SYSTEM UPGRADE PLAN Qo; ,3,,}. ems. °� ELEV: 92.13 (ASSUMEC) ° fi99 MAIN STREET OSTERVILLE MA moo. �O, edye�� ° �° PROPOSED PUMP CHAMBER .�� 0 ' ' RIMS, EL=92.8t Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 - IN UP%c74A ='�/ ABU T TING INV.( )- OWNER OF RECORD Engineering by: Surveying by: SCALE DRAWN JOB. N0. y� � PROPOSED S.A.S. THE 699 MAIN SREET, LLC Engineering Works WARNER SURVEYING 1''=20' P.T.M. 112-08 PARKING 4 ROWS OF 6 - 16" HIGH CAP.(H20) BIODIFFuSERS c/o BRIAN SMITH 12 West Crossfield Road 22 Long Road 1 ROW OF 5 - 16" HIGH CAP.(H20) BIODIFFUSERS 699 MAIN STREET Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. OSTERVILLE, MA 02655 (508) 477-5313 (508) 432-8309 2/22/08 P.T.M. 1 of 3 • -1. ' NOTE: TO PREVENT BREAKOUT DESIGN CRITERIA ~ FINISH UT THE PROPOSED GRADE SHALL NOT BE < EL:92.5 PROPOSED PUMP CHAMBER FOR A DISTANCE OF 15 AROUND THE BUILDING USAGE DI0 CMR 15.203): PROVIDE RISERS WITH METAL FRAMES & COVERS PERIMETER OF THE S.A.S. PROPOSED D-BOX 1ST FLOOR - SUPERMARKET _ 3300 SF x 97 GPD/1000 SF = 320.1 GPD OVER EACH ACCESS MANHOLE AND SET TO FINISH PROPOSED S.A.S. 2ND FLOOR - OFF.,ICE 1180 SF x 75 GPD/1000 SF = 88.5 GPD GRADE. MANHOLES BROUGHT TO GRADE SHALL BE INSTALL H-20 RISER, FRAME INSTALL INSPECTION PORT OVER END UNIT WITH 3RD FLOOR - OFFICE - 865 SF x 75 GPD/1000 FLOW OOO F = 464. GPD GPD SECURED TO PREVENT UNAUTHORIZED ACCESS. & COVER, SET TO FINISH GRADE PTOTAL PROTECTIVE METAL FRAME/COVER SET TO GRADE ACTUAL WATER USAGE: RIM EL.=92.62 RIMS, EL.=92.83(MAX.) F.G. EL: 94.O(MIN.)-97.5(MAX.) 2pp5 _ 1 45,000 GALLONS -.AVERAGE DAILY FLOW = 397 GPD RIM EL.=94.0t 2006 - UNRELIABLE DUE TO LEAK IN WATER SERVICE (REPAIRED) 60" MAX. COVER MAINTAIN 27. GRADE (MIN.) OVER S.A.S. 2007 - 169,000 GALLONS AVERAGE DAILY FLOW = 463 GPD L = 9'(MAX.) L - 8'(MAX) (MIN,) @ S=17 (MIN.) DAILY FLOW: 463 GPD 4"SCH40 PVC 2" SCH 40 PVC 4"SCH40 PVC 6" GEOGRID TO EXTEND 1 FT, BEYOND S.A,S. DESIGN FLOW: 474 GPD a 3" 6 lit" TO SOIL TEXTURAL CLASS: CLASS I r INVERT INSTALL INV.=86.20 INV.=92.17 DESIGN PERCOLATION RATE: <2. MIN./INCH EFFLUENT INV.=92.20 4 ROWS OF 6 UNITS AT 6.33'/UNIT'''=. 38:0' GARBAGE GRINDER: NO FILTER PROPOSED D-BOX AND 1 ROW OF 5 UNITS AT 6.33/UNIT = 31.7' (ZABEL OR EQUAL): INV.=86.30t INV.=86.45 INV.=92.1 1 - • LEACHING AREA REQUIRED: (474) = 640.5 S.F. (EXISTING) 5 OUTLETS (MIN.) SOIL_:gBSORPTION YST M p F) BOTTOM EL.=81.70 -- -.� f34F.IL .74 EXISTING SEPTIC TANK RESTORED PAVED PARKING & BRICK WALKS EXISTING SEPTIC TANK: 1 000 GALLON CAPACTY (TITLE 5 INSPECTION 1/29/02) TO REMAIN PROPOSED PUMP CHAMBER 12" OF COMPACTED GRAVEL + BACKFILL WITH CLEAN NATIVE SAND _ EXISTING GREASE TRAP: 1000 GALLON CAPACITY. (TITLE 5 INSPECTION 1/29/02) EFFLUENT FILTER SHALL BE INSTALLED ON OUTLET PROPOSED PUMP CHAMBER: 1000 GALLON CAPACITY, H-20 RATED TEE AS MANUFACTURED BY ZABEL OR EQUAL. Fh •� PROPOSED D-BOX:: 1 INLET, 5 OUTLETS (MINIMUM), H-20 RATED SHALL BE INSPECTED AND CLEANED ANNUALLY.`- BREAKOUT=TOP OF UNIT _s. BIAXIAL PEPRODUCED 8 TENSAR See Pump Detail, Sheet 3 of 3) TOP ELEV.=92.50 CORP., ATLANTA, GA USE 4 ROWS 0 6 & 1 W OF 5 HIGH CAPACITY 16" ( p INV. ELEV.=92.11 6" ADS BIODIFFUSE S H-20 NO STONE FOR AN S.A.S. BOTTOM ELEV.=91.17 a I ililtll HAVING THE OVERA ENSIONS 14' x 38' NOTES 5' MIN. ABOVE BOTTOM OF SIDEWALL AREA: NOT APPLICABLE 1) PUMP CHAMBER & D-BOX SHALL BE SET LEVEL AND T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH=14.0' TRUE TO GRADE ON A MECHANICALLY COMPACTED BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.7 SF/LF OF BIODIFUSSER) SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN r EXISTING SUITABLE 29 UNITS x 6.33 LF x 4.7 SF/LF = 862.8 SF 310 CMR 15.221(2). NO GROUNDWATER AT EL.=81.20 _ MATERIAL 2) INSTALL INLET & OUTLET TEES AS REQUIRED. (4 ROWS OF 6) + (1 ROW OF 5) = 5 ROWS (29 UNITS) DESIGN FLOW PROVIDED: 0.74 x 862.8 = 638.5 GPD 3) MAXIMUM COVER OVER PUMP CHAMBER, D-BOX AND WITH NO SEPARATION BETWEEN EACH ROW & NO STONE S.A.S. SHALL BE 36". SEPTIC SYSTEM PROFILE BUOYANCY CALCULATIONS N.T.S. NOT REQUIRED. PUMP CHAMBER NOT IN GROUNDWATER. I-- 31_�' -I t SOIL LOG DOSING 8c STORAGE REQUIREMENTS r i J PROPOSED i $ ,, I DATE: FEBRUARY 7, 2007 (REF.# 12094) DESIGN FLOW: 474 GPD S.A.S. I o t 9I SOIL EVALUATOR: PETER MCENTEE PE, CSE DOSING. REQUIRED: 4 CYCLES/DAY (SAND) iv l I- WITNESS: DONNA MIORANDI IRS, CSE 474 - 4 = 118.5 GA S CYC LLLON / LE ___________ TP P-2 Depth Elev. - 1 Depth Elev. : T DISTANCE REQUIRED BETWEEN •PUMP r� 38.0' -i "' 94.2 0" 94.5 0" ON AND PUMP OFF FLOATS: S.A.S. DIMENSIONS - ) PAVEMENT PAVEMENT 118.5 GAL/CYCLE = 250 GAL/FT = 0.4'% FT/CYCLE (USE 0:5 FT.) 8 0 - STORAGE REQUIRED ABOVE WORKING LEVEL: 474 GALLONSr I 93.9 3" 93.2 " 3.. GRAVEL GRAVEL STORAGE PROVIDED: $ ' r I i FILL FILL - - '15' 93.5 INV.(IN) EL:86.20 PUMP ON EL:83.37 - 2.83' r- --- C C STORAGE PROVIDED = 2,83' X 250 GAL/FT = 707.5 GALLONS 40 l I , ' PERC PROPOSED SEPTIC SYSTEM UPGRADE PLAN PROPOSED 6 I . rytp' S.A.S. I 82.2' 4 ME AN 52 ` AND 699 MAIN STREET OSTERVI LLE, M ----------------- U SAND MED. S A 79.9) 2 ,, �. 2.5Y I;/6 2.5Y 6/s Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 �� x , z Y Engineeringb Surveying b SCALEDRAWNOB. NO. 81.2 156" 81.5 156" EngineeringWorks WARNER SURVEYING NTS P.T.M..M 112-08 J./1.S.LAYOUT PERC RATE <2 MIN/IN. ("C" HORIZON) 12 West Crossfield Road 22 Long Road NO GROUNDWATER OBSERVED Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. (508) 477-5313 (508) 432-8309 2/22/08 P.T.M. 2 of 3 `l a Ar NEMA 4 JUNCTION BOX CORROSION RESISTANT & LIQUID-TIGHT CABLE CONNECTORS SUPPORTED BY 1-1/4" PVC CONDUIT. JOINTS TO BE MADE 5-4EA PROVIDE WATERTIGHT CONCRETE RISER WATERTIGHT. USE SJE RHOMBUS-JIB PLUGGER 21 WITH SECURED COVER TO GRADE OR EQUAL. 2" 1 2, INSTALL 1' PVC CONDUIT TO HOUSE FOR WIRING HOISTING CABLE 7x19 STAINLESS STEEL WITH WATERTIGHT JOINTS. WIRE HIGH WATER ALARM x 1/8" DIAMETER. / 1,760 LB. STRENGTH. FLOAT TO GP 2000 HIGH WATER ALARM PANAL ONCIRCUIT SEPARATE FROM CIRCUIT 70 THE PUMP, oINV.(IN)=86.20 2" GATE VALVE (FIELD ADJUST FOR 20 GPM RATE) 2"SCH. 40 DISCHARGE TO D-BOX ALARM ON EL: 84.20 2" 90• ELBOW W/ 1/4" WEEP HOLE cal. Top View Section PUMP ON EL: 83.37 FOR SELF-DRAINING FORCE MAIN D-BOX PUMP OFF EL: 82.87 24 2" SWING CHECK VALVE BOTTOM OF 14 `I, ` PUMP CHAMBER 8" ` -2" SCH. 40 PVC DISCHARGE PIPE J ELEV.= 81.70 3/16" VENT HOLE (MIN.) ABOVE PUMP FLANGE PROVIDE 2- WIDE ANGLE FLOATS: .i 75" FLOAT NOA: PUMP ON/OFF (BARNES 073618) BARNES SEV412 PUMP .5 H.P. 115 V FLOAT NO.2: ALARM ACTIVATION (BARNES 073612) 2" DISCHARGE PASSING 2" SOLIDS PUMP & ACCESSORIES AVAILABLE THROUGH WILLIAMSON ELECTRIC (781) 444-6800 PUMP DETAIL `' �' 76.. LE N.T.S, PR I 16„ 8 TOP 24" DIA. COVERS —` 9 11 4" INLET (TYP.) F t r i POLYSEAL 6" 24" DIA. COVERS I -------------------- -----� (TYP.) —34" —� 2" OUTLET POLYSEAL i— h�'� I I END CAP • SECTION' I I , ---------------- A I 6.3» 5'4" 16'"" HIGH CAPACITY (H-20) BIODIFFUSER UNIT 4'-9» 4'-6" (SEE NOTE 7) 48' i 1� — i 1� — i i MODEL 16" HICAP LIQUID (SEE NOTE 3) I i k � I LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT LEVEL TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY EFFECTIVE LENGTH 75" I I DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. SIDE WALL HEIGHT 11.2" 6" -------------------------------- OVERALL HEIGHT 16" FA 6" BOTTOM 1114 4640 TRUEMAN BLVD OVERALL WIDTH 34" USE OUTLET END (LOWER INVERT) FOR INLET �' A w' `.ICIpI HILLIARD, OHIO 43026 4" POLYSEAL _PLAN VIEW CAPACITY 13.6 CF Elqxs CROSS SECTION A-A (TYP.) (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC. WIGGIN PRECAST CORP 1000H2OGT SPECIFICATIONS 1.) CONCRETE 5,000 PSI AFTER.28 DAYS. PROPOSED SEPTIC SYSTEM UPGRADE PLAN 2.) CONSTRUCTION CONFORMS TO DEP TITLE V REGS. 310 CMR SECTION 15.226. 699 MAIN STREET, OSTERVILLE, MA 3.) TONGUE & GROOVE JOINT SEALED W/ BUTYL RESIN 4.) REINFORCEMENT PER ASTM C1227-93. Prepared for: Brian Smith, 699 Main Street, Osterv.ille, MA 02655 5.) DESIGN LOADING AASHTO HS20 Engineering by: Surveying by: SCALE DRAWN JOB. NO. 6.) INLET TEE SHALL EXTEND TO THE MID DEPTH OF THE TANK(TEES BY OTHERS) EngineeringWorl64 WARNER SURVEYING NTS P.T.M. 112-08 H-20 1000 GALLON PUMP CHAMBER 12 West Crossfie0 Rood H Long Road 12 West C ss ld Road Harwich, MA 02645 DATE CHECKED SHEET NO. (508) 477-5313 (508) 432-8309 2/22/08 P.T.M. 3 of 3 ,. . e - � C�� • t - � , _ � �� . i. ,; { � �—�€� � . .� �; � � � - .. . --- _ .. � } � • .. � - r _ r � 3 � i � � � S , ., �+ 'E { I � �� ' e i 1 Y � i .M f - �. ,. � r i - a - � t j � - •�} � i _ � �� t i + _ 4 _ - � �� -, ., �. t f` � � �. ' , ' ~ ' , i �. •, �� '• ' S. � i .. -, _ � ! ._. > h > - � � .* D . � - � F yg � L � ' .0 , i ✓✓ .. - 4. .. .. ?. - _ � ,i ' , 1 • �` I .. i ' ' �` .. ,. - 4. . 4 y ; .' - �i� � r; :� .. .' _ � � .r s .. e -- � + • � - ,ty . _ .. � r Y _ _ � 5 6 + - S 1' � F 4 r 1 ppr LEGEND N z 910 0) 97,24 x EXISTING SPOT GRADE \ i F a — 92—— EXISTING CONTOUR \ 0- 96 QOk PROPOSED CONTOUR `n � a W EXISTING WATER SERVICE 90 p \ G EXISTING GAS SERVICE �J \ 63 4- O.H.W. EXISTING OVERHEAD WIRES 9131 9p o 3j' \ F Main St 4& EXISTING WATER SHUT-OFF EXISTING GAS SHUT-OFF 914 91 �S S1 ly ? o TEST PIT 9) / •\� g2 41 � \ w'Onn° LOCUS Rd BENCHMARK 1 Qt i �. Aye ea BLDG. � o� s � LOCUS MAP #707 IQ� o• o,� NOT TO SCALE APN 141 - 012 9 �0 �9/•�8 '00. F �o� SAW—CUT PAVEMENT AND INSTALL e�• ' cfl �y� 5 INSPECTION PORTS. MANIFOLD ALL 0�/ a EXISTING 9p o PROPOSEDINSPECTION VENRTSVEN D 20NNECT TO e��oQ / �� BUILDING (#699) i �S `9' TOF=95.10 91� �so � � IIIIIIe � � 988 p 9�Sp �� `y LOT A o.H.w. NOTES: o / 7,486f S.F. 1) OWNER HAS REQUESTED TO WITHDRAW FROM THE Q 0� O SITE SPECIFIC PILOTING PERMIT BY DISCONNECTING APN 141 — THE 0' THE SOILAIR UNIT. BLDG. 984 0{ / 4 I I ( I i I T WATER METER MH 2) OWNER WISHES TO INSTALL A SLUDGEHAMMER S-86 #705 6 \A� I-FLOOR EL.=90.34 I C UNDER THE GENERAL APPROVAL. I•DRAlN' RlM EL.=90.15 3) ADDITIONAL SEPTIC SYSTEM MODIFICATIONS INCLUDE VENT \ ABUTT. SMH NO / ENHANCEMENT, NEW PUMP WITH TIMED DOSING AND�eF l E INSTALLATION OF MORE AGGRESSIVE EFFLUENT FILTERS Q° IN THE GREASE TRAP, SEPTIC TANK AND PUMP: CO 0 �,fib 9 .x�_ t °�6 6� 91981 r-1 S77-1 / / "b. 4 U EXISTING DRY WELL �� aF Mqs ' 9 6,11 ePAR G VENT- 95 4 O 9154 4 �PE S9�yG x _ o TER T. EXISTING SEPTIC TANK McENTEE x ADD ZABEL FILTER (MODEL N0. A1800) o CIVIL i EXISTING GREASE TRAP� �>j\ j�� ADD ZABEL FILTER (MODEL NO. A600) p�F� s/O L E� � NA BENCHMARK NO.1 � 9� ELEV:0F GT 92.13 INLET(ASSUMED)ON o• J � ° D) PROPOSED SLUDGEHAMMER INSTALLATION 699 MAIN STREET OSTERVILLE, MA ` ce / \\oi�. PROPOSED PUMP CHAMBER NT- or, °' RIMS;-EL.=92.8t Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 5 lbINV.(IN)=86.08 P OWNER OF RECORD Engineering by: Surveying by: SCALE DRAWN JOB. NO. \ UP/274A 980 ABUTTING EXISTING S.A.S. THE 699 MAIN SREET, LLC Engineering Works WARNER SURVEYING 1"=20' P.T.M. 182-10 2 4 ROWS OF 6 — 16" HIGH CAP.(H20) BIODIFFUSERS c/o BRIAN SMITH 12 West Crossfield Rood 22 Long Road 1A 83� PARKING Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. F 1 ROW OF 5 - 16" HIGH CAP.(H20) BIODIFFUSERS 699 MAIN STREET OSTERVILLE, MA 02655 1 (508) 477-5313 1(508) 432-8309 7/27/10 P.T.M. 1 Of 2 DESIGN CRITERIA EXTEND VENT;-1 SET 8 —10 BUILDING USAGE (310 CMR 15.2031 ABOVE VENT-2 1ST FLOOR — SUPERMARKET — 3300 SF x 97 GPD/1000 SF = 320.1 GPD 2ND FLOOR — OFFICE — 1180 SF x 75 GPD/1000 SF = 88.5 GPD ADD VENT-2 3RD FLOOR — OFFICE — 865 SF x 75 GPD/1000 SF = 64.9 GPD AIR PUMP IN SET 2' ABOVE GRADE' WATERTIGHT BASIN TOTAL FLOW = 473.5 GPD • ACTUAL WATER USAGE: 110 VAC — EXISTING EXISTING fEAC H VENT SHALL BE 2005 — 145,000 GALLONS — AVERAGE DAILY FLOW = 397 GPD EXISTING - EXISTING ONNECTED TO ALL 2006 — UNRELIABLE DUE TO LEAK IN WATER SERVICE (REPAIRED) ISTRIBUTION LINES 2007 — 169,000 GALLONS — AVERAGE DAILY FLOW = 463 GPD DAILY FLOW: 463 GPD INSPE ION PORTS 2" SCH 40 PVC 6 DESIGN FLOW: ' 474 GPD 7-7 s 11.3" TO DESIGN FLOW PROVIDED: 0.74 x 862.8 = 638.5 GPD INVERT INSTALL EFFLUENT EXISTING EXISTING EXISTING 4 ROWS OF 6 UNITS AT 6.33'/UNIT = 38.0' FILTER(ZABEL OR EQUAL) EXISTING EXISTING EXISTING D—B EXISTING OX AND 1 ROW OF 5 UNITS AT 6.33'/UNIT = 31.7' 5 OUTLETS (MIN.) EXISITNG SOIL ABSORPTION SYSTEM (PROFILE) SludgeHammer* Model S-86 to be EXISTING PUMP CHAMBER installed as shown on Schematic for RESTORED PAVED PARKING & BRICK WALKS General Use Approval CHANGE OUT PUMP 12" OF COMPACTED GRAVEL • Manufacturer: SludgeHammer Group Ltd. oRENCO HIGH—HEAD EFFLUENT PUMP BACKFILL WITH CLEAN NATIVE SAND 336 South Division Rd. EASY PACK AS PROVIDED BY Petosky, MI 49770 ALL CAPE ENVIRONMENTAL ORENCO CONTROL PANEL BIAXIAL GEOGRID / BX1100 MODEL NO. MVP—S1 PT RO TYPE PRODUCED BY TENSAR EXISTING SEPTIC TANK ANCHOR SCIENTIFIC FLOATS :.'.'. '`' = CORP., ATLANTA, GA DOSING 8C STORAGE REQUIREMENTS (ADD ZABEL FILTER, MODEL NO. A100) MODEL NO. SM15N0 *. 6„ DESIGN FLOW: 474 GPD EXISTING GREASE TRA DOSING: PUMP SHALL SET TO RUN AT ONE HOUR INTERVALS OVER (ADD ZABEL FILTER, MODEL NO. A600) 2•8 OVER THE COURSE OF THE DAY. EFFECTIVE WIDTH=14.0' _ PROPOSED FLOATS SHALL BE: EXISTING SUITABLE 1) PUMP OFF MATERIAL 2) TIMER ON/OFF (4 ROWS OF 6) + (1 ROW OF 5) = 5 ROWS (29 UNITS) 3) TIMER OVERRIDE WITH NO SEPARATION BETWEEN EACH ROW & NO STONE 4) HIGH LEVEL ALARM (SET AT 24") EXISITNG SOIL ABSORPTION SYSTEM (SECTION) STORAGE PROVIDED: 2.25' BETWEEN INV.(IN) AND HIGH LEVEL ALARM STORAGE PROVIDED = 2.25' X 250 GAL/FT = 562.5 GALLONS SEPTIC SYSTEM PROFILE N.T.S. t PROPOSED SLUDGEHAMMER INSTALLATION 699 MAIN STREET, OSTERVILLE, MA Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 Engineering by: Surveying.by: SCALE DRAWN JOB. NO. Engineering Works WARNER SURVEYING NITS P.T.M. 182-10 12 West Crossfield Road 22 Long Road Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. 1 (508) 477-5313 (508) 432-8309 7/27/10 P.T.M. 2 of 3 �r ' LEGEND , ' s .• 9� J / 6L\ �jN�� 9 7.2 4 x EXISTING SPOT GRADE 92.... .... EXISTING CONTOUR / a Oak \n c? g6 PROPOSED CONTOUR W EXISTING WATER SERVICE 9Q` p \ D G EXISTING GAS SERVICE \ --' � 91 �' 6`3 � °'l'' r` a — — — EXISTING OVERHEAD WIRES 9 O O.H.W. ,2 o EXISTING WATER SHUT—OFF l �'/ , 1 1, Main St o EXISTING GAS SHUT-OFF 9c��1 / ,/'11 9,7� �S �( -� s �, o 0 TEST PIT M T 9`/, / \�, nc,, LOCUS Rd BENCHMARK _ 1 / ��\ Ave , i EXISTING LEACH PIT £ BLDG. LOCUS MAP 1 i/� �,ea I �, 9 I ,, \, ly NOT TO SCALE #707 1Q a� l f '� o • TO BE PUMPED, FILLED W/ o. � SAND AND ABANDONED jj // VVV"' 6)�I I ] l i I Sa /J �S?47 BENCHMARK N0.2 ,, \ GENERAL NOTES: CTR. OF LP MH COVEREXISTIN 9 `� �� ELEV: 97.41 (ASSUMED) G ( ��e 2 O� y L ��ls �1 / 1 ALL CHANGES H NG S TOTHTHIS PLAN DESIGN BENG PNE PROVED BY THE LOCAL BUILD/NG (#699) . I /� 9 , �_ — TOF 95 10 I PPL2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS A P N 141 — 012 ''I� \ �?' { OF THE STATE ENVIRONMENTAL CODE, TITLE V, AN U ANY AICABLE LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: / — X O.H.W. 310 CMR 15.405(1)(b): 1 g 98g // Sp/ / I LOT A ! t — 1) A 2' variance to the 3' maximum cover requirement, for 5' of 7,486t S.F. max. cover. S.A.S. shall be vented and H-20 Rated, AP N 14� —011 I ° 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR l i y TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE E BLDG 98 I / o� / �4 I _ I I ' T j WATER METER MN DESIGN ENGINEER. 46 ti 1/ ! ' l € C 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING #705 o 6 l r= FLQBR EL =90.34 i ? I FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN / f f DRA/N RIM EL -90.15 ENGINEER BEFORE CONSTRUCTION CONTINUES. \ +4 4 �e� ABUTT. SMH / i �' I € 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. € ? o \ / / I [ 1 E _ 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 0,6 ,� 9p i x 4 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF \ o �� 6 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. e�" / // ,��j �•, 16 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 91` 8. THERE ARE NO PRIVATE WELLS WITHIN 150' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS E'95 4 $, _,,, 9 XIS TING DRY WELL AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. \� RAR G ,, �' c' I ' 10, IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE /� l EXISTING SEPTIC TANK I THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING TP-1 IPJ'J. ) CONSTRUCTION. i / \• ��. INV.�IN =8G.55t OUT)=86.30t OF Mq 11 HERE TP-2 SOILS 7 �� j j��,��,�'I EXISTING GREASE TRAP �P�� SS9�y N THE AREA BENEATHONEATHTANDTO SHALL REMOVE L UNSUITABLE N ALL SIDES OF THE S SIA. ADREPLACE / / \ O� .' \�� y.�� ' INV.(IN)=88.38t �� , WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). �. (( o PETER T. ✓' \� �� ,� y� \ INV, OUT)=88.13f y McENTEE T� 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE \ / ,� ;� ,� �'� 1 54 CIVIL INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. BENCHMARK N0.1 n No. 35109 CTR. OF GT INLET MH StEK``v �Q 98)S oo \+ I�,`�,•' pk kgi\°e / �,.02 ELEV: 92.13 (ASSUMED) PROPOSED SEPTIC SYSTEM UPGRADE PLAN edge e PROPOSED PUMP CHAMBER J (af 699 MAIN STREET, OSTERVILLE, MA y�oc'/ °� RIMS, EL,=92,8t -!� Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 '7 INV. IN =86.08 ( ) OWNER OF RECORD Engineering by: Surveying by: SCALE DRAWN JOB. NO. �\ UP/274A � 98 p ,� ABUT GG PROPOSED S.A..S. THE 699 MAIN SREET, LLC EngineedngWorks OrARNER SURVEYING 1"=20' P.T.M. 112-08 �.� 4 ROWS OF 6 - 16' HIGH CAP,(H20) BIODIFFUSERS c/o BRIAN SMITH 12 West Crossfield Road 22 Long Rood o Tp�F 2 1 ROW OF 5 - 161 HIGH CAP.(H20) BIODIFFUSERS 699 MAIN STREET Forestdale, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. 1 OSTERVILLE, MA 02655 1 (508) 477-5313 (508) 432-8309 2/22/08 P.T.M. 1 of 3 _ t - NOTE: TO PREVENT BREAKOUT, THE PROPOSED DESIGN CRITERIA FINISH GRADE SHALL NOT BE < EL:92.5 PROPOSED PUMP CHAMBER FOR A DISTANCE OF 15' AROUND THE BUILDING USAGE (31 Q CMR 15 203)• S.A.S.PROVIDE RISERS WITH METAL FRAMES & COVERS PERIMETER OF THE 1ST FLOOR - SUPERMARKET - 3300 SF x 97 GPD/1000 SF = 320.1 GPD OVER EACH ACCESS MANHOLE AND SET TO FINISH PROPOSED D-BOX PROPOSED S.A,S. 2ND FLOOR - OFFICE - 1180 SF x 75 GPD/1000 SF = 88.5 GPD GRADE, MANHOLES BROUGHT TO GRADE SHALL BE INSTALL H-20 RISER, FRAME INSTALL INSPECTION PORT OVER END UNIT WITH 3RD FLOOR - OFFICE - 865 SF x 75 GPD/1000 SF = 64.9 GPD SECURED TO PREVENT UNAUTHORIZED ACCESS. & COVER, SET TO FINISH GRADE PROTECTIVE iMETAL FRAME/COVER SET TO GRADE ACTUAL WATER USAGE: TOTAL FLOW = 473.5 GPD RIMS, EL.=92.83(MAX.) F.G. EL: 94.0(MIN.)-97.5(MAX.) 2005 - 145,000 GALLONS - AVERAGE DAILY FLOW = 397 GPD RIM EL.=92.62 RIM EL.=94.0t 2006 - UNRELIABLE DUE TO LEAK IN WATER SERVICE (REPAIRED) W.60" MAX. COVER ;MAINTAIN 2% GRADE (MIN.) OVER S.A.S. 2007 - 169,000 GALLONS AVERAGE DAILY FLOW = 463 GPD L = 9'(MAX.) L e'(MAx) DAILY FLOW: 463 GPD ® 5=1� (MIN) S=t% (MIN.) 6„ GEOGRID TO EXTEND 1 FT. BEYOND S.A,S. i 4"5CH4o PVC 2^ SCH 40 PVC 4'SCH4o PVC DESIGN FLAW: 474 GPD 3" s 11,3" TO SOIL TEXTURAL CLASS: CLASS I 10' INVERT ( ' DESIGN PERCOLATION RATE: <2 MIN./INCH INSTALL J INV.=86.20 INV.=92.17 INV.=92.20 4 ROWS OF 6 UNITS AT 6.33'/UNIT = 38.0' EFFLUENT GARBAGE GRINDER: NO FILTER PROPOSEDD-BOX AND 1 ROW OF 5 UNITS AT 6.33'/UNIT = 31.7' 2ABEL OR EQUAL)'' INV•=86.30t INV.=86.45 INV.=92.11 LEACHING AREA REQUIRED: (474) = 640.5 S•F. (EXISTING) 5 OUTLETS (MIN.) SOIL ABSORPTION SYSTEM (P Og FILE) 74 BOTTOM EL.=81.70 EXISTING ,SEPTIC TANK CROPOSED PUMP CHAIM.E RESTORED PAVED PARKING & BRICK WALKS EXISTING SEPTIC TANK: 1000 GALLON CAPACTY (TITLE 5 INSPECTION 1/29/02) TO REMAIN 12" OF COMPACTED GRAVEL EXISTING GREASE TRAP: 1000 GALLON CAPACITY (TITLE 5 INSPECTION 1/29/02) BACKFILL WITH CLEAN NATIVE SAND EFFLUENT FILTER SHALL BE INSTALLED ON OUTLET PROPOSED PUMP CHAMBER: 1000 GALLON CAPACITY, H-20 RATED TEE AS MANUFACTURED BY ZABEL OR EQUAL. F R ' PROPOSED D-BOX:; 1 INLET, 5 OUTLETS (MINIMUM), H-20 RATED - •� BIAXIAL GEOGRID / BX1100 SHALL BE INSPECTED AND CLEANED ANNUALLY.--- BREAKOUT=TOP OF UNIT TYPE PRODUCED BY TENSAR ++ TOP ELEV.=92.50 ^' ' ` CORP., ATLANTA, GA USE W ROSO 6 & 1 W OF 5HIGH CAPACITY 16 (See Pump Detail, Sheet 3 of 3) INV. ELEV.=92.11 � �• s" ADS 810DiFFUS S H-20 NO STONE FOR AN S.A.S. BOTTOM ELEV.=91.17 II 1 f11 lllll�u HAVING THE OVERA ENSIONS 1 4' x 38' NOTES: 2.8' & D-BOX SHALL BE SET LEVEL AND 5 MIN. ABOVE BOTTOM OF SIDEWALL AREA: NOT APPLICABLE 1) PUMP CHAMBER TRUE TO GRADE & A MECHANICALLY COMPACTED T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH=14.0' BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.7 SF/LF OF BIODIFUSSER) SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN EXISTING SUITABLE 29 UNITS x 6.33 LF x 4.7 SF/LF = 862.8 SF NO GROUNDWATER AT EL.=81.20 _.,.,. MATERIAL 310 CMR 15,221(2). -' 1 DESIGN FLOW PROVIDED: 0.74 x 862.8 = 638.5 GPD 2) INSTALL INLET & OUTLET TEES AS REQUIRED. (4 ROWS OF 6) + (1 ROW OF 5) = 5 ROWS (29 UNITS) 3) MAXIMUM COVER OVER PUMP CHAMBER, D--BOX AND WITH NO SEPARATION BETWEEN EACH ROW & NO STONE S.A.S. SHALL BE 36". SEPTIC SYSTEM PROFILE BUOYANCY CALCULATIONS N.T.S. # NOT REQUIRED. PUMP CHAMBER NOT IN GROUNDWATER. f , f SOIL LOG ' > > ' 'I DOSING & STORAGE REQUIREMENTS J PROPOSED 1 �,f f,f /!f f f!, J ( # ) DESIGN FLOW: 474 GPD DATE: FEBRUARY 7, 2007 REF. 12,094 1 S.A.S. i r' SOIL EVALUATOR: PETER MCENTEE PE, CSE I `>` �f WITNESS: DONNA MIORANDI IRS, GSE DOSING REQUIRED: 4 CYCLES/DAY (SAND) i`? 1 1 I f /7 f f/ r f j/ �' f f f P 474 s- 4 = 118.5 GALLEONS/CYCLE L-------------------�-� / f / Elev. T Depth Elev. TP-2 pith DISTANCE REQUIRED BETWEEN PUMP 38.0' 94.2 0" 94.5 p" ON AND PUMP OFF FLOATS: S.A.S. DIMENSIONS 'f `f e f f ,'I; ; r'�' '1� ' 8' � j f �f �� f j �, �f f f f�f' PAVEMENT PAVEMENT 118.5 GAL/CYCLE -0 250 GAL/FT = 0.47 FTC CYCLE (USE 0.5 FT.) �0• n0�j ;'f s,f ,t ! >% f ; 93,9 3" 93.2 3" STORAGE REQUIRED ABOVE WORKING LEVEL: 474 GALLONS f i' ' /f'�'f; ' f�f f f ff f i ,f ,• GRAVEL GRAVEL STORAGE PROVIDED: FILL FILL , �-- fr 0 f f f .` INV.(IN) EL:86.20 - PUMP ON EL:83.37 = 2.83 f 93.5 r- 93.2 12" 12'1 f f% f f ' f j ` ` ( C C STORAGE PROVIDED = 2.83' X 250 GAL/FT = 707.5 GALLONS I ' ' f fff f f f j';'f f '`I I 40„ PERC PROPOSED SEPTIC SYSTEM UPGRADE PLAN 1 PROPOSED ` , ; S.A.S. 2. 6 ' � 1 ----------------- 1 8 2, 4' 1 �'f f t j j f�; f MED. SAND 52 MED. SAND f 699 MAIN STREET OSTERVILLE, MA NtK 79,9, Z i, 2:5Y 6/6 2.5Y 6/6 Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 81.2 156" 81-5 156" Engineering by: Surveying by: SCALE DRAWN JOB. NO. S.A.S.LAYOUT Engineedngworb AIARNER SURVEYING NTS P.T.M. 112-08 PERC RATE <2 MIN/IN. ("C" HORIZON) 12 West Crossfield Rood 22 Long Road ( NO GROUNDWATER OBSERVED Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. + (508) 477-5313 (508) 432-8309 2/22/08 P.T.M. 2 of 3 �i I , NEMA 4 JUNCTION BOX CORROSION RESISTANT & LIQUID-TIGHT CABLE CONNECTORS SUPPORTED PROVIDE WATERTIGHT CONCRETE RISER BY 1-1/4" PVC CONDUIT. JOINTS TO BE MADE 21„ 5-4" POLYSEAL OUTLETS WITH SECURED COVER TO GRADE WATERTIGHT. USE SJE RHOMBUS-JB PLUGGER OR EQUAL. 2" 2" 1-4' POLYSEAL INLETS I INSTALL 1' PVC CONDUIT TO HOUSE FOR WIRING HOISTING CABLE 7x19 STAINLESS STEEL WITH WATERTIGHT JOINTS. WIRE HIGH WATER ALARM 1/8" DIAMETER. / 1,760 LB. STRENGTH. FLOAT TO GP 2000 HIGH WATER ALARM PANAL ON N _ 0 0 CIRCUIT SEPARATE FROM CIRCUIT TO THE PUMP. In In INV.(IN)=86.20 2" GATE VALVE (FIELD ADJUST FOR 20 GPM RATE) — 06 2"SCH. 40 DISCHARGE TO D-BOX ALARM ON EL: 84.20 2" 90' ELBOW W/ 1/4" WEEP HOLE N Top View Section PUMP ON EL: 83.37 v FOR SELF-DRAINING FORCE MAIN G D-BOX PUMP OFF EL: 82.87 247 2" SWING CHECK VALVE BOTTOM OF 14" --�- PUMP CHAMBER B 2" SCH. 40 PVC DISCHARGE PIPE ELEV.= 81.70 3/16" VENT HOLE (MIN.) ABOVE PUMP F IANGE PROVIDE 2- WIDE ANGLE FLOATS-, FLOAT N0.1: PUMP ON/OFF (BARNES 073618 BARNES SEV412 PUMP .5 H.P. 115 V 75 FLOAT NO.2: ALARM ACTIVATION (BARNES 073612) 2" DISCHARGE PASSING 2" SOLIDS PUMP & ACCESSORIES AVAILABLE THROUGH WILLIAMSON ELECTRIC (781) 444-6800 hall, PUMP DETAIL F r 76" I PROFILE N,T.S, I 16" 8" TOP 9' 11♦2" 4" INLET 24" DIA. COVERS POLYSEAL g^ /� (TYP.) /�. " OUTLET POLYSEAL r-------------------------------- (TYP�A. COVERS 2 I 34„� • • :• _.. I i h"—`— i SECTION END CAP �� --------------- A -�------- - - 6'3" �^ - i '� �`� �' �`� i 16"" HIGH CAPACITY (H-20) BIODIFFUSER UNIT 3" 5,4„ - 4 4'-6" (SEE NOTE 7) q i �� MODEL 16" HICAP LIQUID (SEE NOTE 3) �� i �� _— � i LENGTH 76•, NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT LEVEL i EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY I DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. I SIDE WALL HEIGHT 11,2" 6» L-----------------------------A OVERALL HEIGHT 16" I 6" BOTTOM OVERALL WIDTH 34" 4640 TRUEMAN BLVD USE OUTLET END (LOWER INVERT) FOR INLET 4" POLYSEALS PLAN VIE 11N I' 13.6 CF HILLIARD, OHIO 43026 s CROSS SECTION A-A (TYP.) CAPACITY (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC. WIGGIN PRECAST CORP 1000H2OGT SPECIFICATIONS 1.) CONCRETE 5,000 PSI AFTER 28 DAYS. j PROPOSED SEPTIC SYSTEM UPGRADE PLAN 2.) CONSTRUCTION CONFORMS TO DEP TITLE V REGS. 310 C,MR SECTION 15.226. 699 MAIN STREET, OSTERVILLE, MA 3.) TONGUE & GROOVE JOINT SEALED W/ BUTYL RESIN 4,) REINFORCEMENT PER ASTM C1227-93. Prepared for: Brian Smith, 699 Main Street, Osterville, MA 02655 5,) DESIGN LOADING AASHTO HS20 Engineering by: Surveying by: SCALE DRAWN JOB. NO. s6.) INLET TEE SHALL EXTEND TO THE MID DEPTH OF THE TANK(TEES BY OTHERS) Engineering Worb WARNER SURVEYING NTS P.T.M. 112-08 H 20 1000 GALLON PUMP CHAMBER 12 West Crossfie0 Road H Long Road DATE Forestdole, MA 2644 anvich, MA 02645 CHECKED SHEET N0. (508) 477-5313 (508) 432-8309 2/22/08 P.T.M. 3 of 3 I, -.---- -_ -1 -- - - - -11 - -_ - I - 11 _ -_ , - _ .- I ,� ---. � -r-,,-�, - , . 11 . I i I I -I______ _L,L�_ � � -7____� - . _.___ ,--,-- ___.I-,--.-7-_.-__.-_-- . - .1 - - I I - i - � � f I I I " , -i-! � I : - " . I 11 11-- I . I __ __ I , � �-� ! � � , , � � � f I i I , I . . � I, i ;, , f 11 I ; i , i I t 1 7--��_� ___I-_] '.j._-r-�_I----T-, 1 I.... ..I-!. �T ,-,-.,,- .- . i . _� �_��_ . . � ,!- - � . I � I , --- I . , I - _. , . 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